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Christine M. Bethel

Licensed Marriage and Family Therapist

CLIENT CONTACT SHEET

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Date of Birth
Married/Partner?

Please note: In case of emergency and for your safety, I may need to breach confidentiality to notify your emergency contact.

Your credit card will be charged for services in the event that a session is missed without cancellation or your bill is not paid in a timely manner (At this time a 3.75% processing fee will be added for credit processing).

Christine M. Bethel

Licensed Marriage and Family Therapist

INFORMED CONSENT & SERVICE AGREEMENT

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This consent form is our contract and container, ensuring we begin our work together with clear expectations that define and protect our therapeutic relationship. The client/therapist relationship is unique and highly personal, and at the same time, it is a business contract. Please, initial beside each of the following statements to acknowledge your understanding and agreement.

Session Times:  A standard therapy session runs 50 minutes. Longer sessions are available upon request. 

Fees: Payment is due at the time service is rendered. Please understand that it is your responsibility to keep your account with me up-to-date. Fees per session are currently set at $200.00.

Cancellations: In the event that you must cancel or reschedule a session, a 24-hour notice of cancellation is required to avoid the full fee for the missed session. Insurance companies do not cover missed sessions.

Delinquent Accounts:  If your account has not been paid for 7 days and arrangements for payment have not been agreed upon, I will charge the credit card you provided at intake. If outside resources become necessary to recover outstanding balances you will be responsible for all fees and court costs.

Letter Writing & Phone Calls:  If you request or require a progress report or letter regarding your treatment please note that I charge a fee calculated at 15 minutes based on an hourly fee of $200.00.  Phone conversations, emails and texts exceeding 10 minutes are also billed accordingly.

Client Litigation: I DO NOT participate in client legal proceedings. My policy is NOT to communicate by phone, email or written letter on behalf of clients to court systems or lawyers for the purposes of client litigation.  Additionally,  I DO NOT  write letters on behalf of clients regarding their mental health for schools, disability offices, employers, etc.  Should I be  subpoenaed, despite our signed agreement that this is not within the scope of my provided services, you will be charged time and a half our agreed upon rate, in advance, for each full work day, in advance, to compensate for expenses incurred to provide appropriate coverage for displaced clients.

Confidentiality:  By law, you have the right to confidentiality. I am prohibited from revealing, to any other person, what you have discussed in session without your written permission. There are instances in which your right to privacy may be set aside without your permission (limits to confidentiality):  

  • If you introduce your mental health into a lawsuit, your records may be subpoenaed, I may be deposed, and/or I may be asked to appear in court.

  • If you, your spouse, children or dependent/s have, specifically or vaguely indicated information regarding sexual abuse, physical abuse, emotional abuse and/or neglect of a child, dependent adult or elderly person. I am required by law to report any known or suspected abuses by phone and in writing.

  • If I believe, based on information you disclose, that you are a danger to yourself, I must take reasonable steps to ensure your safety (this may include contacting your spouse or emergency contact to initiate a 24-hour watch or I might call a Psychiatric Emergency Response Team or Police to further evaluate your safety, etc.

  • In the event of a natural disaster whereby protected materials may become exposed.

Communications Privacy: Emails, text messages and phone exchanges are NOT guaranteed to be confidential, despite my best efforts (i.e., security codes on email/cell phone, HIPAA compliant encryption, & promptly deleting messages). By using these means you understand there is potential risk to your privacy.

Couples:  In treating a couple, the client is the couple, not either individual, therefore I strongly discourage secrets. To release information to a third party I need the written authorization of both partners. If I am told anything privately by one member of the couple and believe that it is relevant to the relationship I will encourage that partner to share the information, with my support, in therapy.

Emergencies:  To provide consistently excellent service to you and my other clients, my availability is limited. I am not on call and do not keep emergency hours. I will return non-urgent phone messages within 24 hours Tuesday-Friday 9 am-5 pm. *Please note that I will charge a fee for phone conversations in excess of 10 minutes.

In the event of Medical emergencies/safety concerns, please call 911 immediately. In a mental health crisis, please call:  Multnomah County Crisis intervention: 503.988.4888, available 24 hours a day, 7 days a week.

Termination of Therapy: The length of treatment will depend on the specifics of your treatment plan and the progress we make toward your identified goals. We will discuss termination regularly as we review progress toward your treatment goals. You may discontinue therapy at any time. If either of us is concerned that you are not benefiting from treatment, please bring that to my attention sooner rather than later, I will. Treatment adjustments must be discussed and may include, changing your treatment plan, terminating therapy, or providing a referral.

Consent to Treatment: Please understand that while the course of treatment is designed to be helpful/useful to you, I can make no guarantees about the outcome of treatment. The therapeutic process can bring up uncomfortable feelings and reactions such as, but not limited to, anxiety, sadness and anger. Such reactions and feelings are normal responses to working through unresolved life experiences and these feelings will be actively processed and addressed in the course of therapy.  I am here to support you and work with you throughout this process. I want you to express concerns, ask questions, and allow me to be as useful to you as possible.

HIPAA:  Please click the button to the left to view/download a Notice of Privacy Practices/HIPAA info prior to initialing.

I acknowledge informed consent and agree to the therapeutic expectations and responsibilities outlined in this contract.   

                                                                                                              Cell: 336.337.7886                                                                    © 2025 CBeTherapy                                           1220 SW Morrison St. Suite 535, Box 1

                                                                                                              Email:  cbethelcounseling@gmail.com                                                                                                                        Portland, OR 97205

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