PROFESSIONAL DISCLOSURE STATEMENT Emily Riedl, LMFT 10490 SW Eastridge St. Suite 110D, Portland, OR 97225 www.emilyriedlcounseling.com

503-481-9315

Philosophy and Approach to Counseling: I approach counseling as a deeply personal human endeavor between me and the client, who has invited me into a collaborative partnership to assist him or her in understanding and responding constructively to the needs they express. I believe that clinical effectiveness occurs in the climate of a genuine, caring, and respectful relationship in which the therapist is an ally to the client. This respect empowers clients to take responsibility for their thoughts and behaviors while assisting them in defining their goals and changing the story of their lives. I generally function from a strength-based perspective within Structural Family Therapy. As a Licensee of the Oregon Board of Licensed Professional Counselors and Therapists, I subscribe to the Code of Ethics of the American Association of Marriage and Family Therapists (AAMFT) and the Code of Ethics of the Oregon State Board of Licensed Professional Counselors and Therapists (OAR833-60-001). To maintain my license, I am required to participate in continuing education relevant to this profession. Education and Experience: I hold a Bachelor of Fine Arts degree (Bowling Green State University, 1978) and a Master’s degree in Marriage and Family Therapy (George Fox University, 2004). Major graduate coursework has included Human Growth and Development, Marriage Therapy, Family Therapy, Human Sexuality, Play Therapy, Substance Abuse, Psychopharmacology, and Effective Communication. My experience includes couples counseling, family and blended family counseling, adolescent counseling, crisis counseling, divorce adjustment group work and parenting classes in a group setting. I primarily work with individuals, couples and families. Fee Schedule: Session fees are based on the sliding scale below. Sessions are billed per a 50 minute hour. The client has final responsibility for fees even if insurance is billed. SLIDING FEE SCHEDULE Gross Family Income $0 - $20,000 $20,001 - $30,000 $30,001 - $40,000 $40,001 - $55,000 $55,001 - $80,000 $80,001 or more

3 or less in family $40 $50 $60 $70 $80 $90

4 or more in family $40 $45 $55 $65 $75 $90

Bill of Rights: The following sets forth your rights as a counselee under the Code of Ethics of the Oregon State Board of Licensed Professional Counselors and Therapist (OAR833-60-001). Consumers of counseling or therapy services offered by Oregon licensees or registered interns have the right: a) To expect that a licensee has met the minimal qualifications of training and experience required by state law; b) To examine public records maintained by the Board and to have the Board confirm credentials of a licensee; c) To obtain a copy of the Code of Ethics; d) To report complaints to the Board of Licensed Professional Counselors and Therapists: e) To be informed of the cost of professional services before receiving the services; f) To be assured of privacy and confidentiality while receiving services as defined by rule and law, including the following exceptions: 1) Reporting suspected child abuse; 2) Reporting imminent danger to client or others; 3) Reporting information required in court proceeding or by client’s insurance company, or other relevant agencies; 4) Providing information concerning licensee case consultation or supervision; and 5) Defending claims brought by client against licensee. g) To be free from being the object of discrimination on the basis or race, religion gender, or other unlawful category while receiving services. You may contact the Board at the following address and phone number: Oregon Board of Licensed Professional Counselors and Therapists 3218 Pringle Road SE, #250 Salem, OR 97302-6312 (503)378-5499 For additional information about this therapist, consult the Board’s website at www.oregon.gov/OBLPCT.

Client’s signature ___________________________________________ Date__________ Counselor’s signature _______________________________________ Date__________ .