Jeremiah Guidos, MA

LCPC

208-603-7514

P.O. Box 303

Ponderay, ID 83852

I am pleased that you have selected me as your counselor. The following information is designed to inform you of my background and philosophy as well as to inform you of your rights as a client.

I earned a Masters degree from George Fox University in clinical counseling. I am currently licensed in the state of Idaho and Montana. I have been licensed for many years and participated in many trainings for clinical practice including but not limited to Christian counseling, Rogerian therapy, trauma therapy, grief/loss, addiction(Social media, gambling, sexual, food, etc.), anxiety(general and specific), personality disorders, depression, relationship challenges, neuroscience, attachment, equine therapy, play therapy, family therapy and experiential therapy. I am trained in clinical supervision and clinical ethics as well.

As a licensed clinical professional counselor, I will abide by the American Counseling Association Code of Ethics.

I look at counseling as a journey of personal health and well-being achieved through insight. I approach counseling as a collaborative effort in which the client and I work together on a treatment plan. Together we can discuss treatment goals, objectives, and methods according to your needs. I view my role as one of facilitator. I look to evaluate your lifestyle, choices and goals in order identify unwanted results and/or inconsistencies in your approach. I do this using Rogerian therapy model unless we agree to shift the therapeutic approach for specific needs. Areas of consideration include: Biological-psychological-sociological-cultural-spiritual

You should be aware that counseling presents both benefits and risks as you seek to make changes in your life. Some of the potential risks may include changes in relationships as a result of counseling. This may initially present complications to your circumstances. However, progress in your treatment will be evaluated frequently and modifications in counseling will be made as needed and according to agreed upon treatment goals.

If for any reason, I find that I do not have the experience, training, or knowledge to work with your particular concerns, I will refer you to another professional who is prepared to work with your presenting issues.

Professional Services

Please read the following information and sign the consent to treatment form. Feel free to ask questions about any aspect of the counseling process or office policies and procedures.

Confidentiality

All work provided in is protected by state and federal confidentiality laws as well as professional ethics guidelines. Information shared in session is confidential and can only be released by you, with your written consent or as required by law.

Limits of Confidentiality

As a counselor I am required by law to disclose information you may share pertaining to suspected child abuse, dependent adult and elder abuse, abuse of the developmentally disabled or chronically mental ill, inability to care for one’s basics needs for food, clothing, or shelter, and threatened harm to oneself or others.

I participate in quality assurance procedures, treatment coordination, and clinical consultation at times. Your file may be discussed at these meetings. Any information shared is confidential within those relationships as they are bound by the same confidentiality laws and ethics as I am.

Courts and attorneys may subpoena counseling records. It is my practice to request that your records not be transferred to the courts or attorneys but this isn’t always possible. If subpoenaed to testify in court, I may have to give information harmful to you without your permission. You may want to discuss further limits of confidentiality with me if you believe this may be an issue.

As a client, you have the following rights:

To expect that I have met the minimal qualifications of training and experience required by Idaho and Montana state law as I maintain a license in both states;

To examine public records maintained by the Board and to have the Board confirm credentials of licensee;

To obtain a copy of the Code of Ethics;

To report complaints to the Board;

To be informed of the cost of professional services before receiving the services;

To be assured of privacy and confidentiality while receiving services as defined by rule and law, including the following exceptions:

Report suspected child abuse;

Reporting imminent danger to client or others;

Reporting information required in court proceedings or other relevant agencies;

Providing information concerning intern case consultation or supervision;

To be free from being the object of discrimination on the basis of race, religion, gender, or other unlawful category while receiving services.

You may contact the Board at:

Idaho Bureau of Occupational Licenses

PO Box 83720, Boise,

Idaho 83720-0063

208-334-3233

Email: ibol@ibol.idaho.gov

Web: https://ibol.idaho.gov/IBOL/

Length of Session/Cancellations

Services will be rendered in a professional manner consistent with acceptable ethical standards. Sessions are typically 50-55 minutes in duration depending on services rendered and will be scheduled at mutually agreed upon times. If you must cancel your appointment, please do so promptly so that the appointment time may be open for other clients. There is no charge for sessions cancelled at least 24 hours in advance. You may be charged for a cancellation made within twenty-four hours of your appointment and will be expected to make full payment for any missed appointments not cancelled.

Fees/Method of Payment

The fee for counseling services is due at the time of services. The standard fee for individual therapy is $150.00 per 50-55 minute session. Couples and families are $175 per 50-55 minute session. We offer a same day payment discount as well. Cash or personal checks are acceptable forms of payment as are direct payments through Venmo or other agreed upon method. Checks returned with insufficient funds will add a $25.00 charge to your account. Payments should be made within 30 days of service or late payment fees will apply. Late payment fees are $15 per unpaid session per month and payments are always applied to the oldest session first.

Emergencies

In the event of an emergency please call 911, your local emergency number or report to any hospital, police station or fire station.

Complaint Procedures

If you are dissatisfied with any aspect of your counseling with me, please inform me immediately as I strive to learn and grow. If you believe you have been treated unfairly or unethically by me or any other counselor and have not been able to resolve the problem you may contact:

Idaho Bureau of Occupational Licenses

PO Box 83720, Boise,

Idaho 83720-0063

208-334-3233

Email: ibol@ibol.idaho.gov

Web: https://ibol.idaho.gov/IBOL/

Consent to Treatment

Minor Client: I affirm that I am the legal guardian of . With an understanding of the above information and conditions, I do grant permission for my child to participate in counseling.

Your signature below indicates consent to treatment under the conditions listed above.

Therapist	Client Signature

Date

Client Signature

Date

*By digitally signing, I am acknowledging my agreement with and accuracy of information on this document. I may be asked to initial this document during my first session as well.

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Professional Disclosure Statement

Michele Eave

2023-01-05

jeremiahgu@yahoo.com

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