Professional Disclosure Statement and Informed Consent

Updated: Feb 17, 2021

Rose LPCC 9163 Phone: (530)643-9189

Counseling is a major decision and I am thankful that you have chosen to be here. This consent will be explained to you verbally and I will assist you in understanding my services, policies, and the benefits and risks of counseling, and the limits of confidentiality. This document is our professional agreement.

Education and Qualifications

My name is Rose Atondo and I am an LPCC. I received my Bachelors in Psychology, from Vermont College in 2005. I received my Masters of Science in Clinical Mental Health Counseling from Walden University in 2018. My experience includes, work with Siskiyou County Behavioral Health with both adults, and teens. Working under a licensed therapist in Yreka during my internship in private practice with adults and couples. I am a Gottman method couple’s therapist, I have been trained through level 3, and I am working on becoming certified. While I have taken training in the Gottman Method Couples Therapy, I want you to know that I am completely independent in providing you with clinical services and I alone am fully responsible for those services. The Gottman Institute or its agents have no responsibility for the services you receive. I follow American Counseling Association code of Ethics.

As a licensed professional clinical counselor working with couples using the gottman method I strive to be a caring ear, understanding heart, and respectful to each person’s background in counseling relationships. I seek to empower individuals to reach personal goals, gain insight, heal and/or improve life quality.

Treatment Approach

While working with couples, as well as individuals my hope is to create a safe space to explore what brings you to counseling, and help you regain your connection. I can help you learn to manage conflict in a more constructive way. I am grateful for the opportunity to assist my clients as they explore their goals and resolve the barriers to their success and satisfaction in life. I enjoy helping people resolve relationship conflicts, overcome traumatic experiences, and tap into their inner strength. Therapy can assist you to gain insight into painful experiences, transform patterns that no longer serve you and pinpoint specific issues you may have. Lasting personal growth requires persistent deliberate effort. My goal is to help you feel better while building your self-understanding and skills

Most people find counseling to be emotionally liberating and beneficial. However, specific results cannot be guaranteed, and there are some risks involved. Unpacking long-standing, unresolved problems can trigger uncomfortable memories and feelings. At times, you may experience stress, emotional discomfort, or changes in your relationships. Sometimes it can feel like things are getting worse before they get better. You are likely to gain the most benefit from counseling if you are committed to the process and attend regularly. I welcome your questions and comments about our work together. I will support you and your position throughout the counseling journey. You have the right to request changes in treatment, refuse any treatment that you do not want, or to end treatment at any time. You also have the right to a second opinion, a different approach, or a different counselor and I will give you a referral if needed.

Professional Relationship

It is important to maintain a professional relationship for working together in counseling. It is my policy not to connect with clients through social media such as Facebook, LinkedIn, and Twitter in order to protect your confidentiality as a client. If I receive a request to connect with you, please expect that I will not respond. Also, please do not use these methods to send me messages, as I am not prepared to watch them for important messages from clients.

Client Bill of Rights

As a client, you have the right to:

1. Receive information in a way that is understandable to you regarding:

a) Services/products we provide

b) Any specific charges

c) Billing policies, payment procedures and any changes in the information provided at time of service.

d) Who to contact, when and how to communicate problems with service.

e) Information regarding the organizations liability insurance upon request

2. Receive and access services consistently in a timely manner in accordance with our operational policy; without regard to race, creed, gender, age, handicap, sexual orientation, veteran status or lifestyle.

3. Make informed decisions without health care provider about your treatment plan and use of supplies offered.

4. Be referred to another agency if Rose Atondo is unable to meet your needs or if you are not satisfied with the services, you are receiving.

5. Receive disclosure information regarding and beneficial relationship between Rose Atondo and referred organizations

6. Voice grievances or complaints without reprisal

7. Not receive any experimental products, without full understanding and information

8. Be free from any abusive behavior, neglect or exploitation of any kind by Rose Atondo.

9. Confidentiality of your records


The information you share in the counseling sessions will be kept confidential and never shared without your consent. Limitations to confidentiality to exist with the following exceptions:

(a) CONSENT/REQUEST you direct me to tell someone else, and I agree to do so

(b) THREAT TO YOURSELF OR OTHERS. I decide you are a danger to yourself or others

(c) MANDATED BY COURT OF LAW. I am ordered by a court to disclose information

(d) ABUSE. you disclose abuse of a child, a disabled person, or an elderly person

(e) you disclose that a previous therapist sexually exploited you

Notice of Privacy Practices and Clients Rights

I have been given the HIPPA of Privacy Practice and Clients’ Rights. I understand that the information given below is my preferred contact information for my privacy rights in being contacted.


I charge $150 per hour, with sliding scale available. Must cancel within 24 hours to avoid the $50 late fee.

For marathon therapy, I charge $4000.00. There is a $300 late cancelation fee for marathon therapy. For marathon therapy, it must be canceled 7 days in advance to avoid the fee.


I am licensed with the Board of Behavioral Sciences, they receive and respond to complaints about licenses. Contact them by phone 866-503-3221 or by mail: Board Of Psychology 1625 North Market Blvd., Suite N-215 Sacramento CA 95834

Consent for Treatment of Minors (if applicable)

In the case that in as a parent, I/we consent that my child may be treated as a client by the above referenced counselor.

I hereby consent to and agree to receive counseling services and acknowledge that I have received a copy of the Professional Disclosure Statement for Rose Atondo.

Signature ______________________________________________ Date _________________

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