Gillian DeBruno, MA, Statement of Informed Consent
This form describes some of the policies and procedures that I have developed as part of my holistic practice. At the end of the form, you are asked to sign to indicate your understanding and agreement to holistic mental health services under these conditions. Please read each point carefully, and be sure to ask about anything that may be unclear to you.
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Email *
Client First Name *
Client Last Name *
If client is under age 14, name of legal guardian granting informed consent:
Professional Status. I have worked with children and families since 2001.  I have worked at summer camps and afterschool programs, run leadership trainings/retreats, and managed a tutoring center in a middle school.  I earned my Bachelor of Science in Psychology from the University of Oregon. I then worked with children and families in the foster system.  Before starting graduate school, I was co-running a psychiatric day treatment facility for grades K-6. Upon graduating with a Masters in Marriage, Couple and Family Therapy, I was hired at Kinship House in Portland, Oregon.  I worked there as a family therapist for youth and families touched by the foster and adoptive systems. Since that time, I have moved away from traditional talk and play therapy.  I currently use a holistic approach to mental health support that includes my training in reiki, breathwork, and somatic experiencing.  I am insured by Energy Medicine Professional Association and abide by their code of ethics. *
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Contact Information and Emergencies. I am currently available by appointment only. On occasion, you may find it necessary to contact me by phone outside of our regularly scheduled appointments. I am often not immediately available by phone, due to being involved in sessions with clients and other professional and personal responsibilities. When I am not available, you can leave a confidential voicemail message at (541) 708-3807. My messages are checked regularly Monday afternoon through Thursday, and I do my best to return your message in a timely manner. Crisis, emergent situations, or safety concerns, particularly, client suicidality and/or self-harm or suspected child abuse are the most appropriate reasons to access phone support, however please be aware that I am generally not available outside of identified office hours. Additionally, such matters are best addressed in session and, as such, I will not intervene over email or text message on such matters. In the event of an emergency, you may leave me a message informing me of such but you should also seek more immediate assistance. *
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Community crisis resources include:
For Children and Adolescents:
Mental Health Crisis Team 1-888-989-9990
For Adults:
White Bird (541) 687-4000
Or go directly to your local emergency room. When needed, please call 911 for medical emergencies.
If I am on an extended leave, I will generally have a colleague provide back-up assistance for clients in need. In this event, I will provide you with the practitioner’s name and number and you may seek them out for services.

Psychotherapy Risks and Benefits. Participation in holistic mental health support has been shown to significantly benefit people who undertake it for personal growth, symptom reduction, behavioral change, self-development, skill development, improvements in relationships, increased feelings of well being and reduction in feelings of distress, resolution of specific problems, and the exploration of personal issues and concerns that influence daily life and relationships.Mental health support does, however, carry some risks. Risks may include: uncomfortable feelings which can result from the exploration of difficult or unpleasant aspects of past or current experiences or discomfort from attempts to stretch one-self by engaging in new behaviors, relational skills and coping strategies. For children and adolescents this may manifest in behavioral reactions. Within families, risk can include: the desire to return to or maintain a “status quo” and hesitation to change one’s role in the family so as to support positive sustainable change while working with family members. The most notable risk is a lack of positive impact on presenting concerns.Best outcomes of mental health support are typically associated with the following:- Consistent attendance, active effort and collaboration, both on your part, as the client and/or parent or guardian and on my part as the practitioner.- A positive relationship between practitioner and client. Therefore, if at any time you feel uncomfortable or dissatisfied with our relationship or work, it is important that we discuss this so that we can make the appropriate adjustments to our work together or, if needed, I can assist you with referral to another professional. *
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Diagnosis and Treatment. I do not diagnose conditions, nor do I prescribe substances, nor interfere with the treatment provided by a licensed medical professional. It is recommended that you see a licensed health care professional for any physical or psychological ailment that you have.  If during the course of our sessions we determine that a mental health diagnosis, medication, or higher level of care is needed; I will direct you to the appropriate practitioners and resources. *
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Appointments and Scheduling. After the initial intake appointment(s), which typically last a total of 60-90 minutes, each appointment will usually be approximately 50-60 minutes in length (appointments may run longer on occasion). When we schedule an appointment, I reserve that time especially for you. Therefore, you are responsible for letting me know at least 24 hours in advance of any cancellation for a scheduled appointment. Cancellations should always be made via voicemail. On occasion, I may also have to cancel or reschedule sessions. In such cases, I will attempt to contact you at least 24 hours in advance whenever possible. *
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Confidentiality. I will treat what you share with me in great care. Law protects confidentiality of all communications between a client and a therapist as well as documentation and records. Confidentiality guidelines are determined by Oregon State Law, federal HIPAA guidelines, and my professional code of ethics.Please note, Oregon State Law asserts certain exceptions or limits to confidentiality for cases in which is there is potential harm to the client or others.I am mandated by law to report any suspected abuse and neglect of a child or certain adults.In situations in which I believe you represent a serious bodily harm to yourself or others, I may contact appropriate authorities or seek hospital treatment for you on your behalf.If there becomes some legal involvement in your case, I may be court ordered to release records or testimony. In such cases, I will typically attempt to assert confidentiality, however, a judge may overrule this if he or she determines that this information is necessary.At times, coordination of assessment or support with other professionals or important people in your life may be beneficial to treatment. This would require me to exchange support information with them. In such cases, I will discuss this with you and you should know that law requires I obtain prior written permission from you before releasing any information about our work together. You have the right to refuse to give permission or revoke permission in writing at any time. In general, the sharing of information is done for the sole purpose of benefiting you.I am required to keep a file of our work together for clinical record. All information about you will be under my supervision and kept in a locked file in my locked office. I will participate in regular clinical consultation with my practice colleagues. We routinely discuss cases to assist each of us in providing good quality of services. Any identifying information is left out of these discussions, and again, great care is taken to ensure your confidentiality. All of my colleagues are also bound by the same confidentiality procedures identified above. Generally, no written record or documentation is made of these meetings, although I may note a consultation of your case in your file if indicated. *
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Child/Adolescent Issues. Providing services to children and adolescents may present special challenges in relation to consent to support and confidentiality.By Oregon Law, the custodial parent or guardian is the only person who can provide consent for treatment for children under 14 years old. Please note that a non-custodial parent is only legally able to provide consent for treatment in the case of emergencies when the custodial party is not available. Both custodial parents/guardians and non-custodial parents have the same rights regarding access to treatment information such as discussing treatment with me or reviewing treatment records directly pertaining to the identified client. This does not include access toinformation about others who may be referred to in the records during the course of treatment such as other parents, family members, etc.It is always my goal to increase connection and communication between youth and their parents whenever possible. However, establishing a trusting relationship with a child or adolescent client may require me to sometimes keep some information shared in their sessions confidential from parents. Please note, any information that includes threat of harm to a child/adolescent or other will be shared with parents except when to do so would put a child/adolescent in harm’s way. Always, I encourage parents to share any information or concerns with me about the child/adolescent that would be helpful in understanding them or their support needs. Similarly, parents are always welcome and encouraged to present me with any questions or concerns about the process for discussion and shared decision-making. *
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I strongly discourage the use of treatment with me to further legal goals such as custody evaluation or abuse investigation. These services are outside the scope of my practice. If you are seeking services for legal reasons, we should discuss referral to a more appropriate community resource instead of or in addition to your work with me. *
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Statement of Informed Consent.
By signing this Statement of Informed Consent, I acknowledge that I have read the statement, agree to abide by its terms, and have had any questions or concerns about its contents addressed by Gillian DeBruno. Furthermore, my signature below indicates that I have voluntarily agreed to enter myself or my child into mental health support with her. Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Gillian DeBruno from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).I understand that, by law, I need not sign or enter into this agreement and I may choose to discontinue support at any time.
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