DISCLOSURE STATEMENT

This disclosure statement and the Washington State Department of Health information titled, “Counseling or Hypnotherapy Clients” provides you important information about my professional psychotherapy services and office policies. Please ask questions about this information before signing this disclosure statement. Please initial all sections to show your agreement to policies, and sign and date the last page.

About your Therapist: I am a licensed mental health counselor with a Masters degree in Counseling Psychology from St. Martin’s University. I have over twenty years in the mental health field. I have been self-employed in private practice for fifteen years, working with individuals, relationships and families. I have taught at Seattle Central Community College, Pacific Oaks College, and St. Martin’s University. Additionally, I am conversationally fluent in American Sign Language.

Philosophy, Experience and Style: I offer a holistic approach to counseling which is grounded in psychodynamic, developmental and mind/body psychology. My clinical, teaching and consulting experience includes working with the issues of power, conflict, communication, social justice, anger, depression, addictions, anxiety, anti-oppression, and human development. I work primarily with the modalities of: Sensorimotor Psychotherapy, Self-Relations, Family Systems, Developmental, Attachment theories, and the Enneagram.

Treatment Approach: Interactive psychotherapy is a collaborative effort between client and therapist, my style reflects this. I have a strong commitment to offering: individuals, relationships, families, and

professional clinical services designed to meet their specific needs. To that end, I use a variety of techniques in therapy, tailoring what I do to what I think will work best for each client. Together we will gather your strengths and resources and take the direct route to your stress and/or pain. Through our work you will have more skill and grace to meet yourself and others in what was once before met with fight, flight or freeze responses.   Many clients find that their emotional range will be increased. With a renewed connection to your strengths, you will have more ability to listen to and work with these emotions that you have had difficulty welcoming. We will discern the sensations you feel/don’t feel in your body due to stress and trauma.  Using your emotions, mind, and body what you once experienced as anxiety and depression will have a different meaning and purpose. Although I cannot guarantee a particular outcome, I can say that I give my full attention to working with you in a responsible, caring, thoughtful and professional manner.

Regardless of the length of your therapy, you are most likely to benefit with consistent attendance. At times you may feel ambivalent about your therapy as the process can sometimes be uncomfortable. These feelings are important to discuss in our sessions.

Psychotherapy can have benefits and risks. Since therapy often involves discussing difficult aspects of your life, you may

experience uncomfortable feelings. While they may be initially uncomfortable, we will together likely have a positive outcome and understanding of those feelings. Therapy often leads to better relationships, solutions to problems, and significant reductions in feelings of distress. However, there are no guarantees of what you will experience.

Confidentiality and Professional Records

Information disclosed within sessions, including that of minors, is kept strictly confidential except when the following legal limitations apply:

1) Where there is a reasonable suspicion of child or elder abuse or neglect;

2) Where there is a reasonable suspicion that the client presents a danger of violence to others or where the client is likely to harm themselves unless protective measures are taken; 3) Pursuant to legal proceeding; 4) In the course of my receiving regular professional consultation.

According to the standards of my profession, if you utilize insurance I will keep records of the mental health services I provide you. If necessary, you may see, copy or correct that record. I do not disclose any records to others without your written consent, or unless I am mandated to do so by law. If you are interested in not having any records kept and you are not using insurance we can discuss that as an option.

I welcome feedback from clients at any and all points of our work together. Please feel free to bring up any concerns or questions. These conversations are often a very important

part of the therapeutic process. If you feel unsatisfied about our resolution or otherwise find it necessary to file a complaint, you may do so with the Washington State Department of Health, at (360) 236-4901.

___I use electronic means to communicate with clients including email. I also check my email on my mobile device. While I have a security app for my mobile device, I cannot guarantee your confidentiality. Your initials here indicate that you understand the risk and accept this risk when you contact me by electronic means.

If you do not accept this risk, please only contact me by phone (206) 297-5929, or by mail at 753 N. 35th St. #309 Seattle, WA 98103

Financial Policy Agreement

Professional services will be provided to you at a fee of 120.00 for a 45-minute session, or 180.00 for 75 minute sessions. Payment for each session is expected at the time of services rendered, unless other arrangements are made in advance. If you are using your insurance provider , Client is responsible for co-pay at time of service or deductible not met at time of service. I accept cash or check. If you wish to use your insurance you will need to fill out the Consent for

___ I understand the fees for service and realize I am responsible for any amount not paid by my insurance company.

___ I understand I am expected to know what my mental health benefits are including the number of sessions or deductible.

___ I understand that provider does not bill secondary insurance, and that I am responsible for the co-pay at time of service.

Other fees are as follows: Report writing: $60.00 an hour. Court appearance: $200.00 an hour billed from time of leaving my office to the time of return.

Office Hours and Availability

___ Office hours are by appointment only. Please provide at least 24 hours notice if you need to cancel or reschedule your appointment. Except in an emergency, clients will be charged the full fee of the session if less than 24 hour notice is given. I cannot bill your insurance for a missed appointment.

If you wish to communicate with me by normal email or normal text message, please read and complete the Consent for Non-Secure Communications form included with these office policies.

___ Electronic communication such as email and texting is limited to scheduling appointments unless otherwise agreed upon in writing. If there is a clinical question or concern please contact me by calling my telephone at (206) 297-

5929. If there is no written consent between client & counselor, the counselor will respond to any non-emergent client concerns in session.

Please refrain from making contact with me using social media messaging systems such as Facebook Messenger or Twitter. These methods have very poor security and I am not prepared to watch them closely for important messages from clients. My voicemail is confidential and only heard by me. I check my email every 24 hours. If you have an emergency please respond to my telephone number. Leave me a message if I do not answer (see Emergency Procedure below).

Emergency Procedure

I check my telephone messages and email every business day. If you need to speak with me, please call and leave detailed information of where and when I can reach you. I will call you back as soon as

possible. In case of an emergency, please call the Crisis line at (206) 461-3222 or go to the nearest emergency room, or call 911. When stabilized, please call my office number and leave me a message and contact number. I will contact you as soon as I am able. I do not carry a beeper and do not provide 24-hour emergency call coverage. I will provide follow-up help as soon as possible. Please be sure to discuss with me any questions or concerns you have about this emergency policy.

Please note that SMS (normal phone text messages) are not designed for emergency contact. SMS text messages occasionally get delayed and on rare occasions may be lost.

So, please refrain from using SMS as your sole method of communicating with me in emergencies. Be aware that there may be times when I am unable to receive or respond to messages, such as when out of cellular range or out of town.

Termination of Therapy

Therapy is a joint effort between therapist and client. In

order for the therapy to work, it is vital to keep the lines of

communication open. Please come and talk to me about any

concerns you have at any time during our work together. At

any point in treatment you have the right to terminate

therapy and receive a referral to another therapist. Please

be aware that a therapist also has the right to terminate

therapy: 1) If a therapist feels that it is in the client’s best

interest to

be treated by another professional who has specialized

expertise in the area needed by the client; 2) If a therapist

feels threatened by a client or they are being treated

abusively by a client; 3) If a client repeatedly attempts to

violate the boundaries of the therapeutic relationship; 4) If

the therapist should lose objectivity; and lastly; 5) If a

therapist is not being paid for services.

Washington State Law requires that the following

paragraphs appear on this disclosure statement:

“Counselors practicing counseling for a fee must

be registered or Certified with the Department of

Health for the protection

of Public health and safety. Registration of an

individual with the Department does not include a

recognition of any practice

standards, nor necessarily implies the effectiveness of

treatment”

“The purpose of the Counseling Credentialing Act

(chapter 18, 19 RCW) is (A) to provide protection

for public health and safety; And (B) To empower

the citizens of the State of Washington by

providing a complaint process against those

counselors who would commit acts of

unprofessional conduct.”

I affirm that I am a licensed mental health counselor in the

state of Washington in good standing since 2001. My license

number is LH100005782.

Your signature below indicates that you have read this

disclosure statement and agree to enter therapy under

these conditions. It indicates an understanding that you

may stop therapy if you are not satisfied and/or that I may

recommend stopping the therapy, if in my professional

judgment, the therapy relationship is not working. I have

read the above office, financial, and emergency policies. I

understand these policies and agree to the conditions stated

above.

Client signature: _________________________________

Date:____________________________

Therapist Signature:

________________________________

Date: ____________________________

INFORMATION FORM

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