Professional Disclosure Statement
Douglas W. Pullin, LCSW, LPC, LLC
19 SW Gibbs Street
Portland, OR 97239
(503)293-4177
douglaspullin@gmail.com
Philosophy and Approach:
A relationship that offers deep listening, honesty, respect, and compassion is the foundation for
healing. I work hard to facilitate the necessary conditions for a healing relationship. I am interested
learning about your strengths, goals, feelings and needs. I see strengths as the gateway to
development and positive change. I invite you to embrace your internal resources and strengths
to find meaningful solutions. My focus is to help you to discover freedom from self-limiting patterns
that can lead to stress, conflict and/or withdrawal from life. I offer ways to help you mindfully
observe the unfolding storyline of your life in a less reactive and more compassionate way. I am
totally committed to helping you to clarify and reach your goals.
Educational History:
Lewis and Clark College, Portland, OR. I completed my undergraduate work in June of 1979 and
received a BS degree in psychology. Major coursework focused on developmental psychology,
psychopathology, and behavioral psychology.
Lewis and Clark College, Graduate School of Professional Studies, Portland, OR. I received a
MA degree in counseling psychology in August of 1984. Major coursework focused on cognitive
behavioral psychology, client centered humanistic psychology, and psychological assessment.
Portland State University, Graduate School of Social Work, Portland, OR. I received a MSW
degree in June of 1990. Major coursework focused on person-in-environment assessment, family
systems theory, and self-psychology.
Ethical Practice:
As a licensee of the Oregon State Board of Licensed Professional Counselors and Therapists, I
will abide by its code of ethics. To maintain my license, I am required to participate in annual
continuing education, taking classes dealing with subjects relevant to this profession. I may
substitute professional supervision for a part of this requirement.
Fee:
My fees for: Individual therapy is $120.00; Couples and Family is $140.00. For clients who are
receiving services on a self-pay basis, we will discuss and agree to a fee prior to the start of
services for you and /or your family. For group services, payment in full is due by the end of the
first session. For individual, couples and family services, payment is due at the end of each
session unless another arrangement has been made with me. For clients using insurance
coverage to pay for a portion of the fee, it is your responsibility to learn about the nature and
extent of your coverage. I will bill the insurance provider my standard and customary fee. You
are responsible for paying the difference between my standard or our negotiated fee and what
the insurance company pays. If the insurance company does not pay for my services, you will be
responsible for paying the full fee.
Client Rights:
As a client of an Oregon licensee, you have the following rights:
• To expect that I have 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 service before receiving the services.
• 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 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: one:[email protected]v Website: www.oregon.gov/OBLPCT
For additional information about this counselor or therapist, consult the Board’s website.
Client Signature: ________________________________________Date _______
Parent/Guardian Signature: ________________ _______________Date _________
(Required if client under 14)
Witness Signature: ____________________________________Date _______
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Client Name: ______________________________ Date of Birth: ___________
Address: __________________________________City: __________ State: ____ ZIP: _______
Telephone: (HM) ____________ (WK) ____________ Emai: __________________
Emergency Contact Name: ________________________Relationship to client: ___________
Address: _________________________________City: __________ State: ____ ZIP: _______
Telephone: (HM) ____________ (WK) ____________ Email: __________________
