Practice Policies
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This Notice describes how your protected health information (PHI) may be used and disclosed and how you can access this information.
Please review it carefully. Your privacy is important to us.Under federal and Oregon law, you have the right to:
Receive a paper or electronic copy of this Notice at any time.
Request to review or receive a copy of your health record.
Request corrections to your record if you believe it is incomplete or inaccurate.
Request confidential communication (e.g., contact only by phone or at a specific address).
Request restrictions on how your information is used or shared (though we may not always be able to agree).
Receive an accounting of disclosures of your information made outside treatment, payment, or healthcare operations.
File a complaint if you believe your privacy rights have been violated.
How We May Use and Disclose Your Information
We are allowed or required by law to use or share your health information in the following ways:
For Treatment
To coordinate your care with other providers involved in your treatment (e.g., your primary-care provider, psychiatrist, or referring clinician).
For Payment
To bill and collect payment from you, your insurance company, or a third-party payer. Only the minimum necessary information will be disclosed.
For Healthcare Operations
To evaluate quality of services, compliance, and staff training.
When Required by Law
We may share information:
When required to report suspected abuse or neglect of a child, elder, or vulnerable adult.
To prevent or lessen a serious threat to health or safety.
In response to a court order or other lawful process.
For certain public-health or health-oversight activities.
With your authorization, as required for insurance audits or state program reviews.
Your Choices
You may choose whether your information is shared:
For family involvement in your care.
For appointment reminders by voicemail, email, or text.
For inclusion in fundraising or marketing communications (we currently do not engage in these).
We will obtain your permission before sharing information for any purpose not described in this Notice.
Confidentiality & Electronic Communication
While we use secure electronic systems, no method of communication (email, text, telehealth platform) can be guaranteed 100% secure. If you choose to use text or email for communication, you accept this risk.
Complaints
If you believe your privacy or ethical rights have been violated, you may file a complaint with:
Alyssa Davidson, LCSW
Wandering Minds Counseling & Consulting
Email: alyssa@wanderingmindscounseling.com | Phone: (541) 378-1186
You may also contact:
Oregon Board of Licensed Social Workers
3218 Pringle Rd SE, Suite 120
Salem, OR 97302-6301
Phone: (503) 378-5735 | Fax: (503) 373-1427
Email: blsw.info@blsw.oregon.gov
Website: www.oregon.gov/blsw
You will not be penalized or retaliated against for filing a complaint.Changes to This Notice
We may update this Notice at any time. The revised version will be available in our office and on our website. The effective date will always be listed above.
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Telehealth services allow you to receive mental health care through secure video conferencing rather than in person.
This form explains your rights, responsibilities, and the risks and benefits of engaging in telehealth with Wandering Minds Counseling & Consulting.Telehealth Services
Telehealth sessions use real-time audio and video communication via a HIPAA-compliant platform.
The provider will confirm your physical location at the start of each session for safety and legal compliance.
Services are provided only while you are physically located in the State of Oregon.
The nature of telehealth is similar to in-person therapy except that technology mediates communication.
Potential Risks
While telehealth has many benefits, it also involves some potential risks:
Technology may fail or disconnect during the session.
Confidentiality may be more difficult to ensure if you are in a shared or public space.
Electronic transmission, although encrypted, may be intercepted or accessed by unauthorized individuals.
Not all mental health concerns are appropriate for telehealth. Your therapist may recommend in-person care or higher levels of support if needed.
Confidentiality
The same confidentiality laws that apply to in-person therapy apply to telehealth (HIPAA and ORS 179.505).
Your therapist will take all reasonable steps to protect your information using secure, encrypted systems.
You are responsible for securing your own environment to protect privacy during sessions.Client Responsibilities
You agree to:
Be physically located in Oregon during all telehealth sessions.
Ensure a private, quiet space free of interruptions.
Not record the session without written consent from both parties.
Use a secure internet connection (not public Wi-Fi when possible).
Provide an emergency contact and your physical address at each session.
Emergency Procedures
If you experience a mental health emergency during a telehealth session, your therapist will follow your emergency plan and may contact your emergency contact or local authorities.
If you are in immediate danger, call 911, go to the nearest emergency department, or contact:988 Suicide & Crisis Lifeline (call or text 988)
Douglas County Crisis Line: 1-800-866-9780
Fees & Billing
Telehealth services are billed at the same rate as in-person sessions and are generally covered by most insurance plans, including OHP.
It is your responsibility to verify telehealth coverage with your insurer.Consent for Telehealth
By signing below, you acknowledge that you:
Have read and understood the information above.
Have had the opportunity to ask questions about telehealth services.
Understand the potential risks and benefits of telehealth.
Consent voluntarily to participate in telehealth sessions with Alyssa Davidson, LCSW at Wandering Minds Counseling & Consulting.
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This policy explains your rights to access your mental health records and how Wandering Minds Counseling & Consulting manages requests for copies, summaries, or release of information, in accordance with HIPAA, 42 CFR Part 2 (if applicable), and Oregon Administrative Rule 309-019-0140.
Client Right to Access Records
You have the right to review or request a copy of your treatment records. Requests must be submitted in writing using a signed Release of Information (ROI) form.
In some cases, your therapist may provide a treatment summary instead of full progress notes if it is clinically determined that releasing the full record could cause harm or misunderstanding. You have the right to appeal that decision through the Oregon Health Authority.Fees for Copies or Summaries
To cover time and administrative costs, the following fees may apply:
Type of Request
Fee
Record preparation or summary letter
$150 per hour (minimum 60 minutes)
Electronic copy (encrypted email or EHR portal)
$25 flat fee
Paper copy (up to 20 pages)
$25 flat fee
Additional pages
$0.25 per page
Postage or secure file transfer (if applicable)
Actual cost
Payment is required in advance before records are released. Fees may be waived in cases of transfer of care or hardship. Medicaid recipients are entitled to 1 free copy of their records per year.
Release of Records to Third Parties
Records may be shared only with your written authorization or when legally required. All releases will follow the “minimum necessary” standard, meaning only relevant information will be shared. If your records are subpoenaed, you will be notified before release whenever possible.
Turnaround Time
Wandering Minds Counseling & Consulting will respond to all valid record requests within:
5 business days for acknowledgment, and
30 days for completion (per HIPAA guidelines).
If additional time is needed, you will be notified in writing.
Record Retention
Records are maintained for:
Adults: 7 years from the last date of service.
Minors: 7 years after the client turns 18.
After that time, records may be securely destroyed in compliance with HIPAA and Oregon law.
Client Portal Access (TherapyNotes)
Wandering Minds Counseling & Consulting uses TherapyNotes as its HIPAA-compliant electronic health record system. Clients who are provided with portal access may view or download limited records such as invoices, signed consent forms, or treatment summaries through the secure TherapyNotes Client Portal.
Denial or Restriction of Access
Your request to access records may be denied if:
The information could cause harm to you or another person.
The records contain information about another individual.
The request is part of ongoing litigation.
In such cases, you will receive a written explanation and have the right to appeal.
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Records Requests for Minors
Wandering Minds Counseling & Consulting recognizes the unique privacy rights of minors under Oregon law.
Clients 14 years and older may consent to their own mental health treatment without parental involvement (ORS 109.675).
In these cases, the minor client controls access to their records, and parents or guardians cannot automatically obtain copies without the client's signed authorization.
When therapy is provided to minors under parental consent, parents/guardians may request information about the minor’s participation or progress. However, details shared are at the therapist’s clinical discretion and must balance parental rights with the minor’s right to privacy and therapeutic trust.
The therapist may provide a summary of treatment progress rather than detailed session notes to protect the minor’s confidentiality and safety.
If disclosure is determined to be potentially harmful to the minor, full access may be limited in accordance with ORS 179.505(9) and HIPAA §164.524(a)(3).
DHS & Child Welfare Requests
When the Oregon Department of Human Services (DHS) requests records during a child abuse or neglect investigation:
Mandatory Reporting: The therapist complies with Oregon’s mandatory reporting laws (ORS 419B.010–419B.045) and reports any reasonable suspicion of abuse or neglect.
Investigative Requests: If DHS requests information as part of an official investigation, only the minimum necessary information will be released (ORS 419B.035), such as dates of treatment, attendance, and general treatment status. Clinical notes, trauma narratives, or sensitive psychotherapy details will not be released unless ordered by a court or with written authorization.
Court Orders or Subpoenas from DHS: If DHS or the court issues a subpoena, the therapist will review it with legal counsel, notify the client or guardian when appropriate, and provide only what is legally required. Whenever possible, a treatment summary will be substituted for detailed notes.
Safety and Client Welfare: The therapist may decline releasing specific content if disclosure could cause harm or interfere with therapeutic progress, in accordance with OAR 309-019-0140(8) and HIPAA §164.524(a)(3).
Joint or Family Therapy with Minors
When services involve parents, caregivers, or family members, records are maintained as one integrated clinical record. Access depends on who is considered the “client of record.” If multiple clients are involved, information may only be released with written consent from all parties or as required by law.
Requests from Legal Guardians, Caseworkers, or Attorneys
All requests from DHS caseworkers, legal representatives, or guardians ad litem must be submitted in writing on official letterhead and accompanied by proper documentation or signed release. Wandering Minds Counseling & Consulting may provide a treatment summary instead of raw notes to protect clinical integrity and minimize risk of misinterpretation.
Confidentiality in Foster Care or Open DHS Cases
For clients in foster care or under DHS supervision:
The therapist’s duty is to the identified client, not DHS or foster parents.
DHS may receive limited updates regarding attendance, participation, and safety concerns, but not detailed content unless required by law.
The therapist will collaborate when possible while protecting the client’s therapeutic trust and safety.
Acknowledgment
I understand my rights and responsibilities while receiving counseling services. I acknowledge that myself and/or my child has a right to privacy in therapy, and that certain information may remain confidential unless disclosure is necessary for safety, coordination of care, or as required by law. I understand the process for requesting access to or copies of mine or my child’s records, as well as the limitations and procedures outlined by the therapist.
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Therapy services at Wandering Minds Counseling & Consulting are designed to provide a confidential, supportive space for emotional healing—not to serve as evidence or testimony in legal matters.
Involvement in court proceedings can significantly disrupt the therapeutic process and damage the trust and neutrality required for effective treatment. This policy outlines the procedures and fees associated with subpoenas and court appearances.Court Subpoena & Legal Testimony Policy
Wandering Minds Counseling & Consulting does not provide forensic, custody, or legal evaluation services.
Your therapist will not make recommendations regarding custody, fitness, or capacity determinations and does not testify voluntarily in any legal matter.If you anticipate being involved in a legal case (such as divorce, custody, criminal proceedings, or disability claims), it is strongly recommended that you obtain an independent forensic evaluator or court-appointed expert.
Subpoena Procedure
If a subpoena or court order for records or testimony is received:
You will be notified immediately.
Your therapist will consult legal counsel to determine the validity and scope of the subpoena.
Efforts will be made to protect your confidentiality within the limits of the law.
If you or your attorney subpoena your therapist, you are responsible for all associated costs, regardless of which party issued the subpoena.
Automatic Fee Requirement
Upon service of any subpoena, a non-refundable retainer of $2,500 becomes immediately due and payable, regardless of whether testimony is ultimately given or the court appearance is canceled, postponed, or rescheduled.
This fee covers up to 2 hours of preliminary file review, consultation with legal counsel, and preparation time.
The fee must be received no later than 5 business days before the scheduled court date for your therapist to comply with the subpoena.Fees for Legal Involvement
Service
Fee
Record review, preparation, and correspondence
$250 per hour (2-hour minimum)
Deposition or in-person court appearance
$2,500 per day (includes up to 4 hours on-site)
Additional hours beyond 4 hours
$250 per hour
Travel time (portal-to-portal)
$200 per hour
Mileage
Current IRS rate per mile
Administrative coordination (attorney communication, subpoena handling, document retrieval)
$200 per hour
These fees reflect the disruption to the therapist’s schedule and legal overhead associated with compliance. They are not dependent on case outcome or content of testimony.
Payment in full is required at the time of subpoena service. No testimony or appearance will be scheduled until payment is received.
Therapeutic Relationship & Clinical Risk
Being compelled to testify about your treatment or disclose records in a legal setting can irreparably damage the therapeutic alliance and may result in:
Loss of confidentiality
Disruption of trust and treatment safety
Ethical conflict between the therapist’s clinical and legal obligations
If you or your attorney subpoena your therapist, this action will be considered a formal termination of the therapeutic relationship effective immediately, as the necessary neutrality of the therapist-client relationship can no longer be preserved.
Record Requests
If the court or attorney requires information, your therapist will provide a treatment summary rather than full records whenever legally permissible, in accordance with HIPAA and Oregon law.
Acknowledgment
By signing below, you acknowledge that you have read and understood this policy, agree to the outlined terms, and accept financial responsibility for all related fees should a subpoena be issued.
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This document explains your rights as a client and your responsibilities in the therapeutic process. Wandering Minds Counseling & Consulting complies with all state and federal laws protecting your rights, privacy, and access to quality care.
Client Rights
As a client, you have the right to:
Respectful, Non-Discriminatory Care
To receive services free from discrimination based on race, color, gender identity, sexual orientation, religion, national origin, age, disability, marital status, or source of payment.
Informed Consent & Participation
To be fully informed about your treatment, including goals, methods, potential risks, and benefits, and to participate in creating and updating your treatment plan.
Confidentiality & Privacy
To expect that your personal and health information will be kept confidential as required by HIPAA and Oregon law (ORS 179.505).
Confidentiality may be broken only when:
There is suspected abuse or neglect of a child, elder, or vulnerable adult.
You are in imminent danger of harming yourself or someone else.
Disclosure is required by court order or other law.
Access to Records
To request review or copies of your records and to ask for amendments if information is inaccurate or incomplete.
Grievances & Complaints
To voice concerns or file a complaint without fear of retaliation. Complaints can be made directly to:
Alyssa Davidson, LCSW Wandering Minds Counseling & Consulting Email: alyssa@wanderingmindscounseling.com | Phone: (541) 450-9425 Or to the:
Oregon Board of Licensed Social Workers 3218 Pringle Rd SE Suite 120, Salem, OR 97302-6301 Phone: (503) 378-5735 | Email: blsw.info@blsw.oregon.gov Website: www.oregon.gov/blsw
Choice of Provider & Termination of Services
To request referral to another provider or end services at any time.
Emergency & Crisis Support
To be informed of emergency procedures and receive crisis contact information.
Client ResponsibilitiesAs a client, you agree to:
Participation
Attend sessions regularly and take an active role in your therapeutic process.
Communication
Be honest about your needs, symptoms, and experiences so your therapist can best support you.
Respect
Treat your therapist and staff with courtesy and respect.
Cancellations
Provide at least 24 hours’ notice to cancel or reschedule appointments to avoid late-cancellation or no-show fees.
Payment
Be financially responsible for session fees, copays, deductibles, and non-covered services as outlined in the Financial Agreement.
Safety & Conduct
Refrain from attending sessions under the influence of drugs or alcohol and maintain a safe, respectful environment for both client and therapist.
Technology & Privacy
Use secure, private spaces for telehealth sessions and understand the limits of confidentiality when using electronic communication.
Acknowledgment
By signing below, I acknowledge that I understand and received a copy of the Client Rights & Responsibilities for Wandering Minds Counseling & Consulting.
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This agreement outlines client financial responsibilities and insurance billing authorization in compliance with HIPAA, 42 CFR Part 2 (if applicable), and Oregon Administrative Rules governing behavioral health documentation.
Insurance Authorization & Billing
I authorize Wandering Minds Counseling & Consulting to submit claims to my insurance company on my behalf and release only the minimum necessary information to process those claims in compliance with HIPAA, 42 CFR Part 2 (if applicable), and Oregon law.
I understand that verification of insurance benefits does not guarantee payment and that my insurance carrier determines coverage and allowable benefits after claims are submitted.Client Financial Responsibility
I agree to pay any applicable copayments, deductibles, coinsurance, or non-covered service fees as determined by my insurance plan.
If my insurance company denies or reverses payment, I understand that I am financially responsible for all unpaid balances.
I agree to notify Wandering Minds Counseling & Consulting of any changes to my insurance coverage immediately.
Failure to do so may result in full financial responsibility for unpaid claims.Non-Covered Services
The Oregon Health Plan (OHP) and Umpqua Health Alliance (UHA) cover many behavioral-health services that are medically necessary for your treatment.
However, some services are not covered by Medicaid and may result in out-of-pocket costs if you choose to receive them.
This policy explains what those services are and your rights when deciding whether to pay privately.General Rules
OHP and UHA do not allow balance billing for covered services.
You will never be charged for a covered service that was authorized and billed correctly to OHP.
You may be charged for a non-covered service only if:
You are told in advance that the service is not covered, and
You sign this form to acknowledge and agree to self-pay for it.
(Based on OAR 410-120-1280 and OAR 309-019-0140.)
Common Non-Covered or Client-Pay Services
The following are examples of services or fees that are not covered by OHP / UHA and may be billed directly to you:
Service
Typical Fee
Notes
Missed or late-canceled appointments
$50–$75
OHP cannot be billed for no-shows or cancellations with less than 24-hour notice as well as the therapist can not fill that spot in that time frame.
Record preparation, copies, or summary letters
$25–$150/hr
Applies to personal copies or third-party requests (e.g., attorneys, agencies).
Court testimony, subpoenas, or depositions
$2,000 per day + prep
Legal matters are not covered under OHP. Fees due at time of subpoena.
ESA, housing, or non-medical letters
$50–$300
Not medically necessary under OHP benefit guidelines.
FMLA / disability paperwork (non-medical request)
$50–$150
If requested by employer or attorney, not covered.
Consultation, or professional training
$150 per hour
Educational / non-clinical services are excluded from coverage.
Out-of-state or non-licensed telehealth
Standard session rate
OHP only covers sessions provided while you are physically in Oregon.
Services beyond OHP authorization limit
Standard session rate
Sessions after your approved visits may be self-pay if re-authorization is not approved.
Rates are approximate and may vary by service type. A Good Faith Estimate can be provided upon request.
Client Rights
You have the right to decline any non-covered service without penalty to your care.
You may request a Good Faith Estimate before scheduling or paying for a non-covered service.
If you are unsure whether something is covered, please ask before scheduling.
Payment Methods
Payment is due at the time of service unless otherwise arranged. Accepted forms of payment include credit/debit cards, HSA/FSA cards, cash, or check.
Returned or declined payments may incur a $25 processing fee. Balances older than 60 days may result in suspension of services until payment arrangements are made.Credit Card Authorization
By choosing to keep a credit card on file, I authorize Wandering Minds Counseling & Consulting to securely store my card information and charge for session fees, copays, or late-cancellation fees as outlined in practice policy.
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This disclosure explains how technology, including artificial intelligence (AI)-assisted tools, may be used within Wandering Minds Counseling & Consulting to support clinical documentation, administrative efficiency, and quality of care. It ensures that clients are fully informed about how technology is used, consistent with HIPAA, 42 CFR Part 2 (if applicable), and Oregon Administrative Rules (OAR 309-019-0105) regarding client rights and confidentiality.
Use of Secure Platforms
All scheduling, billing, and clinical records are stored and managed through TherapyNotes, a HIPAA-compliant electronic health record (EHR) platform. TherapyNotes uses encryption and multi-factor authentication to safeguard your protected health information (PHI) in compliance with the HIPAA Security Rule (45 CFR §164.302–318).
Use of AI-Supported Tools
Wandering Minds Counseling & Consulting may use AI-assisted software such as TherapyFuel, TherapyNotes Smart Features, or similar HIPAA-compliant tools for limited, professional purposes including:
Generating or formatting clinical notes from therapist-entered data.Organizing or summarizing non-identifying information to support accuracy.
Improving documentation efficiency, billing accuracy, and timely recordkeeping.
All AI-assisted work is reviewed, edited, and finalized by Alyssa Davidson, LCSW, before it becomes part of your record. No AI tool is used to make independent clinical judgments, diagnoses, or treatment decisions.
Provider Accommodation & Rationale
As a neurodivergent clinician with ADHD, I use AI-assisted tools as a professional accommodation to support executive functioning challenges such as time management and documentation completion. These tools help ensure that all clinical notes are timely, complete, and objective—reducing the risk of personal bias or recall error that can occur when notes are written long after sessions.
This use of technology is not only an accessibility support but also a clinical safeguard that enhances quality, accountability, and ethical accuracy in documentation.Data Privacy & Confidentiality
No identifying or sensitive client information is entered into non-HIPAA compliant systems.
All AI tools used within TherapyNotes or TherapyFuel operate in HIPAA-secure environments under Business Associate Agreements (BAAs).
If de-identified information is used for formatting or workflow purposes, all personal identifiers are removed prior to use.
Your PHI is never shared, stored, or sold outside of secure systems.
Client Rights
You have the right to:
Request that your PHI not be used in any AI-assisted documentation process.
Ask questions about the specific tools used to support recordkeeping.
Withdraw consent for technology-assisted documentation at any time, in writing.
Your decision to opt out will not impact your ability to receive therapy or the quality of your care.
Compliance & Oversight
All AI-assisted documentation and technology use complies with:
HIPAA Privacy & Security Rules (45 CFR §160 & §164)
OAR 309-019-0105 (Client Rights & Informed Consent)
OAR 309-019-0140(3) (Clinical Documentation Standards)
NASW Code of Ethics Sections 1.03, 1.07, and 1.07(m) (Use of Technology & Competence)
Acknowledgment
I have read and understand the above information regarding the use of AI and technology-assisted tools at Wandering Minds Counseling & Consulting. I understand that these tools are used ethically, securely, and with clinical oversight, and that they also serve as a professional accommodation for my therapist’s ADHD and executive functioning support needs.
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Wandering Minds Counseling & Consulting is committed to making therapy accessible and affordable for all clients. Sliding scale fees are available to clients who are paying privately and demonstrate financial need. This form helps determine a fair session rate based on your household income and circumstances.
Eligibility
Sliding scale rates are available only for:
Clients who are not using insurance coverage (private pay only), or
Clients whose insurance does not cover services provided, and
Clients who can document financial hardship or limited income.
Clients must provide medicaid denial that is less than 30 days old.
Clients using Medicaid (OHP) or other insurance are not eligible for sliding scale adjustments on covered services.
Instructions
Please review the income guidelines below and select the range that most closely matches your current gross household income (before taxes). Rates are based on a standard 45–60 minute session.
Household Annual Income
Estimated Monthly Income
Sliding Scale Rate
Under $25,000
$2,083 or less
$75 per session
$25,001 – $35,000
$2,084 – $2,916
$100 per session
$35,001 – $50,000
$2,917 – $4,166
$125 per session
$50,001 – $65,000
$4,167 – $5,416
$150 per session
Over $65,000
Over $5,417
Standard Rate ($200 per session)
*Note: Sliding scale fees apply to standard psychotherapy sessions (CPT 90837/90834). Specialized services such as ESA evaluations, court reports, or consultations remain at full rate.
Acknowledgement
By signing below, I affirm that the income information provided is accurate to the best of my knowledge.
I understand that:Sliding scale eligibility may be reviewed every 6 months or upon significant income changes.
If my financial situation improves, I will inform my therapist so my rate can be adjusted accordingly.
I may be asked to provide documentation (e.g., pay stub, unemployment statement, or benefits letter).
Failure to provide truthful information may result in termination of the reduced-rate agreement.
Selected Sliding Scale Rate
☐ $100 ☐ $125 ☐ $150 ☐ Standard Rate ($200)
HIPAA & OAR Compliance Statement
This agreement complies with OAR 309-019-0215(2) regarding equitable access to care and OAR 309-019-0140(6) regarding documentation of client financial arrangements. All financial records and identifying information are protected under HIPAA and Oregon confidentiality law (ORS 179.505).
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Wandering Minds Counseling & Consulting occasionally provides Emotional Support Animal (ESA) documentation for established clients when clinically appropriate and ethically justified.
This policy explains the criteria, process, and fees for ESA letters and helps ensure compliance with Oregon law, federal Fair Housing Act (FHA) guidelines, and the National Association of Social Workers (NASW) Code of Ethics.Clinical and Ethical Requirements
To be considered for an ESA letter, a client must meet all of the following conditions
:
Metric
Required Standard
Clinical Source of Verification
Established Clinical Relationship
Client has engaged in a minimum of 3 therapy sessions within the last 6 months, allowing sufficient time to assess stability, functioning, and clinical need.
Attendance and engagement records in EHR.
Mental Health Diagnosis
Client meets DSM-5-TR criteria for a qualifying mental health disorder (e.g., Major Depressive Disorder, PTSD, Generalized Anxiety Disorder, or similar) that significantly impacts daily functioning.
Diagnosis and treatment plan documented in record.
Functional Impairment
Documented evidence that the mental health condition substantially limits one or more major life activities (e.g., sleep, concentration, socialization, or self-care).
Clinician assessment and progress notes.
Benefit of ESA
Clinical evidence supports that interaction with or presence of an animal provides measurable symptom reduction or emotional stabilization (e.g., reduced panic frequency, improved sleep, increased social engagement).
Self-report, symptom tracking, or therapist observation.
Stability and Responsibility
Client demonstrates consistent follow-through with appointments, emotional regulation, and ability to safely care for an animal without neglect or harm.
Attendance records and therapist observation.
Therapeutic Appropriateness
ESA use aligns with the treatment plan and is not contraindicated (e.g., avoidance-based coping, increased dependency).
Clinical judgment documented in treatment summary.
Limitations and Ethical Standards
ESA letters are not issued when:
The client is new to therapy or has not completed sufficient sessions for a valid assessment.
There is no qualifying mental health diagnosis or impairment.
The requested letter is primarily for financial, housing, or pet-related convenience rather than therapeutic need.
The client exhibits unsafe behaviors toward animals or lacks the capacity to care for one.
The ESA is requested for public access or travel purposes (ESA letters under this policy apply to housing only).
Process
If all required metrics are met:
The client and therapist will discuss the request during a scheduled session.
The therapist will review documentation and complete an ESA evaluation note.
If clinically appropriate, a letter will be issued outlining the qualifying diagnosis, treatment relationship, and therapeutic benefit, consistent with Fair Housing Act guidelines.
If the metrics are not met, the therapist will provide written notice explaining that the request cannot be ethically fulfilled at this time.
Fees
ESA letters are not covered by insurance, including the Oregon Health Plan (OHP) or Umpqua Health Alliance (UHA).
A flat fee of $300 is due prior to completion of the assessment and issuance of the letter.
This fee covers:The assessment review and consultation,
Documentation and preparation time, and
Follow-up administrative correspondence if needed.
If the therapist determines that an ESA letter is not clinically appropriate, the assessment fee remains due for time and professional evaluation.
Updates or Renewals
ESA letters are valid for 12 months from the date of issue. Renewals require a brief reassessment session to confirm continued clinical need and are subject to the same ethical standards and fee.
Acknowledgment
By signing below, I acknowledge that I have seen this policy and I understand that ESA letters are not guaranteed, are provided only when clinically appropriate, and are not covered by insurance.
I understand the $300 flat fee is due prior to letter completion and is non-refundable once the assessment has been conducted. -
Under the No Surprises Act, health care providers must give clients who are uninsured or self-pay an estimate of expected charges for services.
This Good Faith Estimate (GFE) outlines potential costs for therapy with Wandering Minds Counseling & Consulting.Estimated Services
Service Description
CPT Code
Estimated Cost per Session
Typical Frequency
Annual Estimate*
Initial Diagnostic Evaluation
90791
$250
Once
$250
Individual Psychotherapy, 45 min
90834
$200
Weekly or Biweekly
$4,550–$9,100
Individual Psychotherapy, 60 min
90837
$225
Weekly or Biweekly
$5,200–$10,400
Individual Psychotherapy, 30 min
90832
$175
Weekly or Biweekly
-$3,900-$7,800
Emotional Support Animal Assessment
N/A
$300
Yearly
$300
Crisis or Extended Session up to 75 Minutes
90839
$250
As needed
N/A
Extended Crisis (additional 30 minutes after initial 75 minutes)
90840
$120
As needed
N/A
Case Management, Report Writing, or Coordination of Care
N/A
$50-$150
As needed
N/A
*Annual estimate assumes 26–52 sessions per year for ongoing therapy.
Additional Notes
These costs are only estimates and may change based on your unique treatment plan, progress, and scheduling frequency.
Additional services (e.g., letters, forms, or court-related documentation) may result in additional fees, which will be discussed in advance.
The Good Faith Estimate does not obligate you to receive or continue services.
If you are using insurance, this form does not apply—your out-of-pocket costs will depend on your plan’s benefits, copays, and deductibles.
Dispute Resolution Rights
If you receive a bill that is $400 or more above this Good Faith Estimate, you have the right to dispute the charge.
To start the dispute process, you must submit a request in writing to the U.S. Department of Health and Human Services (HHS) within 120 days of receiving the bill.
Visit www.cms.gov/nosurprises or call 1-800-985-3059 for more information.
You may also contact Alyssa Davidson, LCSW, at Wandering Minds Counseling & Consulting with any billing concerns.Acknowledgment of Policies
By signing below, I acknowledge that I have received and reviewed the practice’s extended policies, including but not limited to the Good Faith Estimate, Emotional Support Animal (ESA) Policy, AI & Technology Use Policy, Sliding Scale Fee Policy, and Credit Card Authorization.
I understand that these documents are provided for informational and compliance purposes and do not obligate me to participate in, request, or receive any specific services. I further understand that fees, services, and applicable policies may vary based on my individual circumstances and needs, and that acknowledgment of receipt does not constitute a binding agreement for services beyond those separately agreed upon in my treatment.
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Wandering Minds Counseling & Consulting complies with applicable federal civil rights laws, including Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and Section 1557 of the Affordable Care Act, as well as all Oregon Administrative Rules (OAR 309-019-0215).
We do not discriminate on the basis of race, color, national origin, age, disability, religion, sex, sexual orientation, gender identity or expression, marital status, pregnancy, veteran status, or socioeconomic background. All clients have the right to receive services in an inclusive, culturally sensitive, and affirming environment.
If you believe you have been discriminated against, you may file a complaint directly with Wandering Minds Counseling & Consulting or with:
Oregon Health Authority, Behavioral Health Division
500 Summer St NE E86, Salem, OR 97301 | 503-945-5763U.S. Department of Health & Human Services, Office for Civil Rights (OCR)
200 Independence Ave SW, Washington DC 20201 | (800) 368-1019 | www.hhs.gov/ocr
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Wandering Minds Counseling & Consulting utilizes HIPAA-compliant technology platforms to protect client privacy. Telehealth sessions are conducted through encrypted systems such as Google Workspace (with Business Associate Agreement), TherapyNotes, or SimplePractice.
While every effort is made to safeguard confidentiality, please note:
Email and text messaging are not fully secure and may be intercepted or misdirected. These are used only for scheduling, billing, and administrative communication.
Clinical content should not be shared by text or email.
Electronic records are stored on password-protected, encrypted devices.
Clients assume the inherent risk of using electronic communication.
By communicating electronically, you acknowledge and accept these limitations.
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Wandering Minds Counseling & Consulting maintains professional social media accounts for the purpose of sharing general mental health education, practice updates, and community resources. These platforms are not used for providing clinical services or communicating with clients.
To protect your privacy and maintain appropriate therapeutic boundaries:
No clinical communication occurs through social media.
Messaging features on platforms such as Facebook, Instagram, TikTok, and others are not secure and may compromise confidentiality. Scheduling, clinical questions, or personal concerns must be communicated through phone, email, or the secure client portal.Your therapist will not accept friend requests, follow client accounts, or interact with client content online.
This includes declining or not responding to friend requests, follows, tags, comments, or invitations through personal or professional profiles. These boundaries help protect your privacy and maintain a consistent therapeutic relationship.Public engagement may reveal your identity.
If you choose to engage with the practice’s public posts by liking, commenting, sharing, or tagging, other users may see your name or profile. Wandering Minds Counseling & Consulting cannot prevent visibility of public engagement and encourages clients to consider their privacy needs before interacting with content.Reviews and testimonials cannot be acknowledged.
Ethical and legal guidelines prevent your therapist from responding to online reviews because doing so could confirm a therapeutic relationship. You may leave a review if you choose, but your therapist will not respond to protect your confidentiality.Your therapist does not monitor or search client social media.
Your online activity will not be reviewed or used in treatment unless you explicitly request it and provide written consent. Even with consent, this is done only when clinically appropriate.Social media is not monitored for emergencies.
If you are in crisis or experiencing a safety concern, do not use social media to contact your therapist.
For emergencies, call 911, contact the 988 Suicide & Crisis Lifeline, or go to the nearest emergency department.
You may ask questions about this policy at any time.
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Practice PoliciesNotice of Non-Discrimination
Technology & Email Security Policy
Social Media Privacy & Communication Policy
Consent for Care Coordination
You may authorize Wandering Minds Counseling & Consulting to coordinate with your primary care provider, psychiatrist, or other treatment professionals to ensure continuity of care.
Information shared will be limited to the minimum necessary for coordination—typically diagnosis, treatment progress, or medication updates.
You may restrict or revoke this consent at any time in writing by notifying your therapist.This authorization will automatically expire one year from the date signed or upon termination of treatment, whichever occurs first. No information will be disclosed without written authorization except as required by law.
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You have the right to express concerns or dissatisfaction regarding your care or experience without retaliation or risk of losing services.
If a concern arises, you are encouraged to:
Discuss the issue directly with your therapist whenever possible.
If unresolved, submit a written grievance describing the concern to: Alyssa Davidson, LCSW, ADHD-CCSP Wandering Minds Counseling & Consulting Email: alyssa@wanderingmindscounseling.com
Your grievance will be acknowledged within 5 business days and reviewed promptly. A written response and resolution will be provided within 30 days.
If your grievance is not resolved, you may contact:
Oregon Board of Licensed Social Workers 3218 Pringle Rd SE, Suite 120, Salem, OR 97302 | (503) 378-5735 | blsw.info@blsw.oregon.gov
Oregon Health Authority Client Rights Office 500 Summer St NE E86, Salem, OR 97301 | (503) 945-5763
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Wandering Minds Counseling & Consulting is committed to providing a therapeutic environment that is safe, respectful, and free of harassment or discrimination.
Client responsibilities include:
Refraining from verbal, written, or physical aggression toward staff or others.
Attending sessions while sober and free from the influence of intoxicating substances.
Ensuring telehealth sessions take place in a private, stationary environment (no driving or multitasking).
If behavior compromises safety or therapeutic effectiveness, services may be paused or terminated, and appropriate referrals or crisis supports will be offered.
Your therapist is a mandatory reporter under Oregon law and must take action if serious safety concerns arise.
Ethical Rationale & Provider Statement
As an independent provider, I reserve time specifically for you each week and do not double-book or overfill my schedule. When appointments are missed or canceled without adequate notice, I am unable to offer that time to another client in need.
I understand that unexpected situations arise; however, as a small private practice, my income depends on appointments being kept. Frequent late cancellations or no-shows make it difficult to sustain the availability and quality of care I strive to provide. This is why the cancellation policy exists — not as a punishment, but as a way to respect both of our time and ensure the continued stability of my practice.
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Appointments must be canceled or rescheduled with at least 24 hours’ notice by email, voicemail, or through your client portal.
Late Cancellation (less than 24 hours): $75 fee
No-Show (missed appointment): Full session rate
Insurance (including OHP) cannot be billed for missed or canceled appointments.
Repeated missed sessions may result in transition to as-needed care or termination.
After two consecutive late-canceled appointments or no-shows, you will be removed from your recurring appointment slot and placed on an individual scheduling basis.It is your responsibility to reach out and reschedule after missed appointments. If you have been removed from the recurring schedule due to lack of engagement or communication, future sessions will be scheduled one at a time until consistent attendance is reestablished.
Exceptions may be made for illness, family emergencies, or power/technology failures at the therapist’s discretion.
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If a session is interrupted or canceled due to inclement weather, power outages, or technology failure:
Your therapist will attempt to reconnect for up to 10 minutes.
If reconnection fails, you will receive a follow-up call or email to reschedule.
You will not be charged for canceled or incomplete sessions caused by verified disruptions.
Clients are encouraged to keep a backup phone number on file in case of telehealth connection issues.
This policy supports consistent care while recognizing the realities of Oregon’s weather and telecommunication challenges.
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To support high-quality care and maintain professional competency, I participate in ongoing case consultation with licensed clinicians through Juniper Tree Counseling and other qualified peer providers. Case consultation is a standard, ethical practice in mental health and is required by the NASW Code of Ethics and Oregon Administrative Rules (OAR 309-019-0140 and 309-019-0105) to ensure clients receive safe, competent, and supported services.
During consultation, no identifying information (such as your name, date of birth, or contact information) is shared. Cases are discussed in a de-identified manner, focusing only on clinical themes, treatment planning, or support needs. This process protects your confidentiality while allowing me to access the professional peer support necessary for providing high-quality, ethical care.
You may ask questions about this process at any time.
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Your confidentiality is protected under HIPAA, 42 CFR Part 2 (if applicable), and Oregon Revised Statutes (ORS 179.505 & 676.260). However, your therapist may be required or permitted by law to release information without your consent in the following situations:
If there is reasonable cause to believe a child, elder, or vulnerable adult is being abused, neglected, or exploited.
If you are in imminent danger of harming yourself or another person.
When records are ordered by a court or required by law.
When consultation or supervision occurs (information will be de-identified whenever possible).
To comply with audits, billing requirements, or mandated public-health reporting.
Your therapist will make every effort to discuss these disclosures with you in advance whenever clinically and legally appropriate.