Deborah Lyman

LCSW


Authorization to Receive Mental Health Services
(Informed Consent)

I authorize Deborah Lyman, M.S.W., L.C.S.W., to provide mental health services to me. I understand that psychotherapy has both benefits and risks. I will participate in an assessment and, together with the therapist, develop a treatment plan in accordance with my goals and needs. I understand that occasionally individuals may undergo periods in therapy which may result in emotional discomfort, changes in their relationships or temporary worsening of their symptoms. This should subside as the work progresses. I retain the right to request changes in treatment or terminate treatment at any time.

APPOINTMENTS:
I agree to keep scheduled appointments. If it is necessary to cancel an appointment, I will do so 24 hours in advance or at the earliest moment. If an appointment has been missed, without notice to cancel or reschedule, I understand that I will be charged for that session.

FEES:
Counseling services are $130 per 60-minute session. Deborah will help with your insurance billing.

EMERGENCIES:
For emergencies, I understand that I can leave a message at 541.572.4024. If I feel immediate attention is required, I can access help by dialing 911 or go to my nearest emergency department.

CONFIDENTIALITY:
I understand that the fact that I am in treatment or any information about me will be kept confidential and that I must authorize in writing any disclosure of information to another person or agency. I also understand that Oregon law limits my confidentiality when my therapist believes that I am a danger to myself or any other person, or when a child, a disabled person, or elder (age 65 or older) is being, or has been, abused. In the event that confidentiality must be breached, my therapist will make every effort to discuss the matter with me first.
MY SIGNATURE ABOVE INDICATES THAT I HAVE READ AND UNDERSTOOD THIS STATEMENT OF INFORMED CONSENT.