Individual, Marriage and Family Therapist
P. Roger Hillerstrom M.A., L.M.H.C.

Treatment Disclosure Form

Your counselor is P. Roger Hillerstrom, MA, LMHC, License #LH0005938

Your counselor’s education, training and experiences include:
BA, Psychology. Bethel College, St. Paul, MN 1978
MA, Marriage and Family Counseling, Biola University, La Mirada, CA 1982
Community Corrections Counselor
Community Mental Health Therapist
Adjunct Professor of Marriage and Family, Puget Sound Christian College
Clinical Family Therapist since 1982

Your counselor’s therapeutic orientation: 
Cognitive/Behavior, Strategic Family Systems

Client’s cost per counseling session for treatment, where known:
Standard customary fee is $165 per 50-minute session.
Insurance is billed when applicable. A sliding fee scale is available in which fees are adjusted according to annual income.  

Late fees will be assessed for overdue accounts.

Additional fees may be charged for testing and reports when necessary.

Counselors practicing counseling for a fee must be registered, certified or licensed with the Department of Licensing for the protection of the public’s health and safety. Registration of an individual with the Department does not include recognition of any practice standards nor does it necessarily imply the effectiveness of any treatment.  

I have been provided with a copy of the disclosure information as well as the Notice of Policies and Practices Statement and understand the information provided.

Client Signature  __________________________________ Date ________

Printed client name _______________________________