Professional Disclosure Statement
This notice Provides Information About the Background of the Therapist, the nature and boundaries of the counseling relationship, and your rights as a client.
Please Review it carefully.
*For the purposes of this document, the word or phrase “I” will refer to Emboldened Mental Health as an organization and/or any of it’s care providers, including staff members.
WELCOME TO EMBOLDENED MENTAL HEALTH
As a Licenced Mental Health Counselor in the State of Washington (License # LH61242998), I am providing the following disclosure of information, policies, and procedures so you are able to be fully informed about my professional services and offer your consent to treatment. The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together.
For the purposes of this document, “counseling” and “psychotherapy” are considered to be equivalent terms. Counseling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. The American Counseling Association defines “counseling” as a “professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals.” As a client in counseling, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Please read and indicate that you have reviewed this information, agree to it, and give your consent for treatment by filling in the checkbox and/or signing your name at the end of this document.
THERAPEUTIC PROCESS: RISKS AND BENEFITS
You have taken a very positive step by deciding to seek therapy. For counseling to be effective, you and I both must be actively involved in the therapeutic process, both developing counseling goals and assessing progress. Work both in sessions and outside of sessions is required to facilitate change and growth. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself. The benefits to this process include gaining insight into your problems, finding support and help, developing coping skills and resources, and changing yourself in order to pursue wholeness and healing.
LICENSE & TRAINING INFORMATION
I received my Bachelor of Arts degree in 2010 from California State University, Long Beach. Then, I completed my Education Specialist degree in School Psychology at the University of Washington in 2014. I am a Nationally Certified School Psychologist and am licensed in the state of Washington. I have received specialized training in Cognitive Behavioral Therapy, Trauma-Focused Cognitive Behavior Therapy, Suicide Prevention, and Dialectical Behavior Therapy.
CLIENT RIGHTS IN COUNSELING
At any point in counseling, you may raise questions about the counselor, the therapeutic approach, the progress of the counseling, and the cost of services. It is your right and responsibility to choose a counselor and counseling modality that best suits your needs. You may request a change in counseling approach, referral to another counselor, or to refuse treatment at any time. The most important thing is that you get the kind of help and support that you need, even if that means working with a different counselor.
CONFIDENTIALITY
The session content and all relevant materials to your treatment will be held confidential unless it is requested in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
If a client threatens or attempts to commit suicide or otherwise conducts themself in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
RECORDS
All patient health information (PHI) and documentation are confidential and protected in accordance with state and federal law. Your information is stored and maintained in accordance to HIPAA standards via practice management software called SimplePractice. Upon written request via a signed Release of Information (ROI) form, your records (excluding psychotherapy notes) can be shared with other professionals (e.g., a psychiatrist for medical referral).
MINORS
If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
AVAILABILITY AND SCHEDULING
My direct phone number is 425-256-3546 and I can be accessed by phone/voicemail or text. Typically, I am only available during scheduled appointments. For non-urgent matters, please feel free to contact me via the online Client Portal (https://emboldenedmentalhealth.clientsecure.me/) or via my secure textline (425-256-3546). I will return the message within 1-2 business days. Scheduling appointments with me may be done in-person or online via the Client Portal.
Appointments vary in length and in frequency, so we will schedule our sessions according to your needs and by mutual agreement. If you are unable to keep an appointment, please provide at least 24-hour notice to cancel or reschedule.
EMERGENCIES
I am not immediately available in emergency situations. If there is no immediate physical danger but you still need emotional support and/or crisis intervention, call or text 988, or chat at 988lifeline.org, for 24/7 support. If you feel that you are in immediate danger or are having a medical emergency, please call 9-1-1 and request emergency assistance.
FEE SCHEDULE AND PAYMENT
*80-Minute Adult Diagnostic Intake: $200
*50-Minute Child/Adolescent Diagnostic Intake: $150
*50-Minute Adult Individual Counseling Session: $150
*80-Minute Individual Counseling Session: $200
*50-Minute Child/Adolescent Individual Counseling Session: $150
*50-Minute Family Session: $200
*80-Minute Family Session: $250
Fees are payable at your session, via debit, credit, or HSA/FSA cards on the online Client Portal (https://emboldenedmentalhealth.clientsecure.me). Please note that a fee may be applied to credit card transactions. For your convenience, I also offer an “auto-pay” option and can accept payments through PayPal or Cash App (inquire for more information). Receipts for all fees paid will be provided online; hardcopies are available upon request.
Fees are subject to change at the discretion of Emboldened Mental Health. In the event of a fee change, you will be notified prior to your next scheduled session.
INSURANCE
I do not accept insurance at this time but can provide a monthly receipt (“Superbill”) if you wish to submit it to your insurance company directly for reimbursement. If you have a health insurance policy, it will may offer some coverage for mental health treatment. I will provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. You should be aware that submitting claims to your insurance company requires a mental health diagnosis and carries a certain amount of risk to confidentiality, privacy, and to future capability to obtain health or life insurance. The risk stems from the fact that mental health information is likely to be entered into insurance companies' computers and is likely to be reported to the National Medical Data Bank. Clients are responsible for interacting with their insurance providers and for therapy payments. As with most insurance questions, it is a good idea to call your insurance company directly to verify coverage before receiving services.
CANCELLATIONS AND NO-SHOWS
Since the scheduling of an appointment involves the reservation of time set aside especially for you, a minimum of 24 hours notice is required for rescheduling or the cancellation of an appointment. If for any reason a session is canceled less than 24 hours prior, or you fail to attend the appointment (considered a “no-show”), a $75 fee will be charged via the payment method on file. Please note that most insurance does not reimburse for missed sessions and the client will be responsible for the full $75 fee. If you are late for a session, you may lose some of that session time and will still be billed for the entire session fee.
TELEPHONE ACCESSIBILITY
If you need to contact me between sessions, please leave a message on my voice mail or send me a message via the online Client Portal secure messaging system or my HIPAA secure textline (425-256-3546). I am often not immediately available; however, I will attempt to return your call or message within 24 hours. Please note that virtual face-to-face/Telehealth sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.
ELECTRONIC COMMUNICATION
Emboldened Mental Health uses a HIPAA compliant client portal as an electronic health record system called Simple Practice. All information is encrypted to ensure your personal health information cannot be compromised. The Simple Practice servers are housed in a secure facility protected by proximity readers, biometric scanners, and security guards 24 hours a day, 7 days a week, 365 days a year.
Emboldened Mental Health also uses iPlum for telephone communications with clients. iPlum is a secure and HIPAA-compliant communication platform that encrypts all phone calls, text messages, and voicemails to secure and protect client information.
Although I exercise due diligence to secure all forms of communication with my clients, I cannot ensure the confidentiality of any form of communication through electronic media, including email and text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
SOCIAL MEDIA POLICY
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). The American Counseling Association has specific guidelines in their ethical codes regarding social media and clients; adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
Consumer Review Sites: I do not solicit or request testimonials or consumer reviews. I do not claim pages on such sites as Google, Yelp, or Healthgrades. Leaving a review compromises your confidentiality. Please refrain from leaving consumer reviews online. If you have concerns or complaints about the services you have received, please speak to me directly.
Use of Search Engines: I will not conduct electronic searches about clients unless there is a genuine emergency where information obtained electronically might protect a client from harm.
TERMINATION
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
Please note that should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued. If I do not have contact or communication from you for a period of 30 days, I will assume that you no longer intend to remain active in this therapeutic relationship and your case will be closed. You can return to therapy in the future, depending on my availability, if you decide to continue treatment.
COMPLAINT PROCEDURES
If you believe that I have acted unprofessionally, you have the right to contact the Washington State Department of Health so you may obtain a copy of the acts of unprofessional conduct listed under RCW 18.130.180. The contact information for reporting is: The Washington State Department of Health, Health Professions Quality Assurance Division, at:
P.O. Box 47869
Olympia, WA 98504-7869
Phone: (360) 236-4902 [Mondays through Fridays, 8am to 5pm]
CLIENT AGREEMENT
You are encouraged to discuss any questions or concerns you have about entering a counseling relationship with me or about the counseling process that I have described. If you have any questions at any point, please engage with me and share these as often as they arise.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on September 1, 2019. This notice has been revised and updated as of January 2024.