Good Faith Estimate Notice

Jennifer Ungarwulff, LPC Mother Heart Counseling

104 N. First St., Suite 12

Silverton Oregon 97381

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit: No Surprises

Professional Disclosure Statement

Jennifer Ungarwulff, MS, LPC
104 N. First Street Suite 11 Silverton, Oregon 97381

Philosophy and Approach: My approach to counseling is grounded in my belief that all people have an inborn ability to overcome difficult obstacles in their lives, and move toward a state of health. I believe each person is an expert on their own life; therefore my primary focus is on helping clients become more deeply connected to their own capacity for inner guidance. I believe change occurs in therapy through mindful exploration and integration. I utilize a collaborative approach that incorporates humanistic, depth oriented and experiential models of therapy.

Education and Training: I hold a Masters degree in Counseling from Portland State University. Major coursework focused on developing skills and techniques for providing therapy with couples, families and individuals.

As a Licensed Professional Counselor, I abide by the Oregon Board of Professional Counselor and Therapists Code of Ethics. To maintain my license I am required to participate in continuing education which includes taking courses on; clinical technique and theory, diversity and inclusion, suicide prevention as well as ethical issues relevant to this profession.

Fee Schedule: My fee is $120.00 per 55-minute session. I can offer discounted sessions to clients committed to attending weekly therapy sessions and who have economic constraints. My Sliding scale fees range from $90-$125 per 55-minute session.

Clients Rights: As defined by rule of law [OAR 833-100-0021(14)].

• To expect that a licensee has met the minimal qualifications of training and experience required by state law:

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

• To obtain a copy of the Code of Ethics;

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

• To report complaints to the Board of Licensed Professional Counselors and Therapists

  at: 3218 Pringle Rd. SE, #120, Salem, OR 97302-6312. Telephone: 503/378-5499 Email:

  lpct.board@oregon.gov Website: www.oregon.gov/OBLPCT

• To be assured of privacy and confidentiality while receiving services as defined by rule

  of law with the following exceptions: 1) Reporting suspected child abuse 2) Reporting imminent danger to self or others; 3) Reporting information required in court proceedings or by client’s insurance company, or other relevant agencies; 4) Providing information concerning licensee case consultation or supervision; 5) Defending claims brought by client against licensee; 6) When written permission to communicate to a third party is given. In the case of minors the legal guardian must grant this permission.

• To be free from being the object of discrimination on the basis of race, religion, gender,

or other unlawful category while receiving services.

Client Responsibilities:

As a client you have the following responsibilities:

• Be an active participant in therapy:

  o Provide the necessary information to facilitate treatment.
  o Help plan your goals.
  o Work to achieve identified goals
  o Discuss any discomfort, concerns or questions that may arise regarding your

  therapy.

• Inform therapist of any additional mental health treatment you are receiving.

• Set and keep appointments. Provide at least 24-hours notice if you must miss an

  appointment.

• Payment for treatment is due at time services are rendered.