Forms

Good Faith Estimate

You have the right to receive a “Good faith Estimate” explaining how much your medical care will cost

Effective January 1, 2022, a ruling went into effect, called the "No Surprises Act".  Under the law, health care providers need to give patients, who do not have insurance or who are not using insurance, an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs, like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your healthcare provider gives you a Good Faith Estimate, in writing, at least 1 business day before your medical service or item. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you received a bill that is at least $400.00 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 www.cms.gov/nosurprises or call (800) 368-1019.

 If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

  • Authorization to Disclose Information Form

Note: To download Adobe Acrobat Reader for free, Click here.





Professional  Disclosure Statement:

Professional Disclosure Statement

Meghan Smith, LPC, NCC

Meghan’s Place: Outpatient+ Eating Disorder Therapy

10700 SW Beaverton-Hillsdale Hwy Suite 696

Beaverton, Oregon

971-205-0408

 

Philosophy and Approach: My theoretical orientation approaches change from a behavioral approach. By drawing on cognitive-behavioral therapy and dialectical behavioral therapy through a wellness lens, a cohesive model of change emerges which emphasizes all client's capability of change if given the right tools. Negative behaviors or nonadaptive behaviors are merely a symptom of lack of healthy coping strategies and the inability to cope with circumstances in a healthy manner. All thoughts and behaviors can change to become more adaptive for the client's life and future goals.I also recognize the importance of emotional regulation and the need for client buy-in for treatment to be successful. My specific focus is directed towards individuals who struggle with body image issues, disordered eating patterns and food anxiety. I also use a collaborative model in my practice along with motivational interviewing techniques with sensitivity to client's individuality and cultural experience. 

 

Formal Education and Training: I hold a master’s degree from Lewis and Clark College in Professional Mental Health Counseling. I also hold a certificate in eating disorder diagnosis and treatment from Lewis and Clark College. As a Licensee of the Oregon Board of Licensed Professional Counselors and Therapists, I am required to participate in continuing education, taking classes relevant to subjects relevant to the profession. I also do consult with other colleagues in the field on a monthly basis to discuss helpful treatment interventions and to ensure you are receiving the most helpful care. During these consults, your private information is protected. 

 

Fees:  I take a variety of insurance plans to help with payment with services. For a complete list of insurance companies that are in-network with me, please ask.  Initial consultations are complimentary. Individual counseling sessions (55 minutes) are $145 per session. Additionally, I commit to providing lower fee sessions or pro bono sessions to 15% of my clients on an ongoing basis. Prior to the start of the first counseling session, all clients will be made aware of the financial obligations pertaining to therapy. Please cancel sessions at least 48 hours in advance to avoid being charged for a session. 

 

As a client of an Oregon Licensed Professional Counselor, you have the following rights:

 ∗ To expect that a licensee has met the 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 (Oregon Administrative Rules 833-100);

 ∗ 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 or law, with the following exceptions: 1) Reporting suspected child abuse; 2) Reporting imminent danger to you or others; 3) Reporting information required in court proceedings or by your insurance company, or other relevant agencies; 4) Providing information concerning licensee case consultation or supervision; and 5) Defending claims brought by you against me;

 ∗ To be free from discrimination because of age, color, culture, disability, ethnicity, national origin, gender, race, religion, sexual orientation, marital status, or socioeconomic status.

 

You may contact the Board of Licensed Professional Counselors and Therapists at 

3218 Pringle Rd SE, #120, Salem, OR 97302-6312 Telephone: (503) 378-5499

Email: [email protected]  Website: www.oregon.gov/OBLPCT

 

For additional information about this licensee, consult the Board’s website.

 

 


Location

Availability

Monday:

Closed

Tuesday:

9:00 am-8:00 pm

Wednesday:

9:00 am-8:00 pm

Thursday:

9:00 am-8:00 pm

Friday:

9:00 am-8:00 pm

Saturday:

9:00 AM-5:00 PM

Sunday:

Closed