Resources – A Safe Place To Talk

Some Self Help Resources

New resources and book suggestions will be added on a regular basis – check back often

Important Paperwork

Community Resource Guide

Domestic Violence

Clackamas County Crisis and Support Line

Clackamas Mental Health Center

Clackamas Health Centers – Behavioral Health Services

Additional Support Services

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Safe Place to Talk – Thomas Deshler PhD.

1230 Division Street, Oregon City, Oregon 97045
Office (503) 655-5327 | Cell (503) 983-8813

Please fill out the document below and click "Submit" when complete

Patient

First Name

Last Name

Provider

First Name

Last Name

I understand that I must be in the state of Oregon at the time of my appointment, or the appointment will be cancelled.

I understand that Telehealth Services (real-time audio / video teleconference sessions) involves the use of electronic information and communication technologies by a mental health care provider to deliver services to an individual when he/she is located at a different site than the provider; and I hereby consent to Provider delivering healthcare services to me by way of a telehealth modality.

I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth. As always, your insurance carrier and SPtoT will have access to your medical records for quality review / audit.

I understand that there are risks and consequences from telehealth services including, but not limited to, the possibility, despite reasonable efforts on the part of my provider that the transmission of my personal information could be disrupted or distorted by technical failures and/or the transmission of my personal information could be intercepted by unauthorized persons.

I understand that I will be responsible for any copayment, deductible or coinsurance that apply to my telehealth services. This may or may not be the same cost as face-to-face sessions.

I understand that I have the right to withhold or withdraw my consent for the use of telehealth services at any time during the course of my care, without affecting my right to future care or treatment. I can revoke my consent orally or in writing by contacting my provider. As long as this consent is in place and has not been revoked, my provider may offer mental health care services to me via electronic means without the need for me to sign another consent form.

I understand that my provider will contact me via a secure, HIPAA compliant electronic platform (such as Doxy.me). I also understand that it is my responsibility to choose a location, a time, a network, and a device that maintains my privacy and prevents interruption during our telehealth session. Barring any unauthorized breaches of security, I agree that no one will record, listen to, or watch our session without permission from both of us.

By signing this document, I agree that certain situations, including emergencies and crises (such as thoughts of harm to self or another, uncontrolled psychotic, or manic symptoms, experiencing a life-threatening situation, abusing drugs or alcohol or other concerns which may present a risk to my safety) are inappropriate for audio/video and/or computer-based telehealth services. If I am in crisis or I am experiencing a medical or psychiatric emergency, I should immediately call 911 or go to the nearest hospital or crisis facility

First Name

Last Name

Email Address

Is the client a minor?

Yes No

Date

Signature

Safe Place to Talk – Thomas Deshler PhD.

1230 Division Street, Oregon City, Oregon 97045
Office (503) 655-5327 | Cell (503) 983-8813

Authorization for Recurring Credit/Debit Card Payment

This form authorizes “Safe Place to Talk” to charge your redit/debit card for services rendered.

Client Information

Name

Email

Phone

Address

City/State/ZIP

Card Information

Name on Card

Card Number

Expiration Date

CVV Code

Billing ZIP Code

Authorization Terms

By signing this form, you authorize

Your Practice Name

to charge the credit/debit card listed above for services provided as follows:

1. Authorization for Recurring Payments

You agree to allow “Safe Place to Talk” to automatically charge your card after each session for the full amount of the session fee.

2. Fee Schedule

Session fees are as follows:

The agreed upon fee shall be $

Missed Appointment (without 24-hour notice): $ 25.

3. Termination of Authorization

This authorization will remain in effect until:

You notify “Safe Place to Talk” in writing to cancel this authorization. Email is adequate Deshler@safeplacetotalk.com
Your account is closed, or the credit card provided expires or is no longer valid.

4. Security of Information

Your card information will be securely stored and processed in compliance with applicable laws and industry standards

5. Disputes and Refunds

You agree to contact “Safe Place to Talk” in the event of any disputes or questions regarding charges.

Acknowledgment and Agreement

I, the undersigned, certify that I am the authorized cardholder for the card listed above and that I have read, understood, and agree to the terms of this agreement.

Client Signature

Date

Provider Signature

Date

Some Self Help Resources

Important Paperwork

Community Resource Guide

Domestic Violence

Clackamas County Crisis and Support Line

Clackamas Mental Health Center

Clackamas Health Centers – Behavioral Health Services

Additional Support Services

QUICK LINK

Contact Us

Safe Place To Talk – Thomas Deshler PhD.

CLIENT INTAKE EVALUATION

1. IDENTIFYING INFORMATION

2. HAVE YOU EVER BEEN IN COUNSELING BEFORE?

3. MEDICAL INFORMATION

4. SUBTANCE USE HISTORY

Safe Place To Talk – Thomas Deshler PhD.

INFORMED CONSENT AND OFFICE POLICIES

CONSENT TO TREATMENT

Professional Fees and Billing Practices

Safe Place to Talk – Thomas Deshler PhD.

Please fill out the document below and click "Submit" when complete

Patient

Provider

Safe Place To Talk – Thomas Deshler PhD.

CONFIDENTIALITY INFORMATION FORM

Safe Place to Talk – Thomas Deshler PhD.

Client Satisfaction Form

Safe Place to Talk – Thomas Deshler PhD.

Authorization for Recurring Credit/Debit Card Payment

Client Information

Card Information

Authorization Terms

1. Authorization for Recurring Payments

2. Fee Schedule

3. Termination of Authorization

4. Security of Information

5. Disputes and Refunds