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Amirah David, MA, NCC

PROFESSIONAL DISCOLURE STATEMENT



Philosophy and Approach: I believe that children, youth and families can reach a sense of
wellness and fulfillment in their lives. I employ an eclectic and integrated approach to
counseling depending on individual client and family needs, drawing from various theories,
methods, and life experiences including emotion-focused therapy, person-centered therapy,
mindfulness techniques, narrative therapy, family systems theory, existential therapy, depth
psychology, cognitive-behavioral therapy, and elements of dance and movement therapy as well
as somatic and body-oriented approaches. I believe our thoughts, feelings, sensations,
experiences, behaviors, beliefs and symptoms are all part of an integrated whole, and therefore
seek to support the whole person in a collaborative and relational manner.

Formal Education and Training: I hold a Masters Degree in Counseling Psychology from
Lewis and Clark College: Graduate School of Counseling and Education. Major coursework
included: group, family and couples counseling; human growth and development with an
emphasis in child and adolescent adjustment; trauma and crisis intervention; diversity, social
justice and cultural awareness; and assessment and diagnosis of mental and emotional disorders.
I also completed one year of coursework in the Education Specialist degree program. I have
completed a 6-month facilitation-training program called The Heart of Facilitation, and several
advanced Effective Communication and Relationship Building Seminars. I am trained in several
forms of dance and movement.

As a Registered Intern of the Oregon Board of Licensed Professional Counselors and
Therapists, I will abide by its Code of Ethics. I am under the ongoing supervision of Maria
Connoly, MS, CHT, LPC, and therefore consult with her about my counseling practice in order
to provide the best services possible to my clients. My supervision sessions are held to the same
strict confidentiality standards as my counseling practice, and any information shared is for the
sole purpose of advancing my learning and skills as a counselor and to ensure the best possible
treatment for my clients. I am happy to explain this further.

As a client of an Oregon Board Registered Intern you have the following rights:
To expect that a registered intern has met the minimal qualification of training and
experience required by state law;
To examine public records maintained by the Board to have the Board confirm
credentials of registered intern;
To obtain a copy of the Code of Ethics;
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
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
proceedings or by clients insurance company, or other relevant agencies; 4) Providing

information concerning registered intern case consultation or supervision; and 5)
Defending claims brought by client against registered intern;
To be free from discrimination due to age, color, culture, disability, ethnicity, national
origin, gender, race, religion, sexual orientation, marital status, or socioeconomic status.

Fees: I charge on a sliding scale. Fees due at time of service. I do not bill insurance.

Cancellations: Sessions are scheduled by appointment and are usually 60 minutes in length.
This time is reserved for you. If you need to cancel your appointment, a 24-hour notice is
required. You will be charged for your appointment if you fail to provide 24-hour advance
notice of cancellation. Please call immediately if you need to cancel or reschedule your
appointment. You can leave a message 24 hours a day. The phone number is: (503)926-2218.

Emergencies: In case of an emergency, related to your treatment with me, please call my
cellular phone at (503)926-2218. If you are unable to reach me in an emergency, please call the
Helpline at 541-779-4357.

*You may contact the Board of Licensed Professional Counselors and Therapists at 3218 Pringle
Rd. SE #250, Salem, OR 97302-6312. Telephone: (503)378-5499 Email: lpct.board@state.or.us
Website: www.oregon.gov/OBLPCT


RELEASE OF INFORMATION/AGREEMENT CONSENT TO TREATMENT

I have read, or I have had read to me, the above information and have had the opportunity to ask
questions about it. I understand my rights to privacy and the exceptions to my rights to privacy.
In the event children are to be involved in treatment, I hereby give my consent for their treatment
and affirm that I am a legal guardian with the authority to authorize mental health services. I also
agree to abide by the payment and billing policy outlined above and accept full responsibility for
any and all fees incurred in my care or the care of my children.

Please sign below to show that you have read and understood this Information Consent
Statement:

Date: __________________

Print Name ____________________________ Signature _______________________