Counseling Disclosure Statement

Mary Peters, MA, LMHC, PS, Inc. State Of Washington Licensed Counselor, LC00046555 NPI 1568570612 EIN 80-0357363 631 5 th Street, Suite 201 Mukilteo, WA 98275 Counseling Disclosure Statement Thank you for deciding to seek my help for your current needs. To facilitate our work together, please review the following important information about my services, your legal rights and your financial obligations. Please be sure to clarify any questions or concerns you might have before signing the following agreement. Approach to Treatment I provide psychotherapy to children, adolescents, and adults that will be designed to meet your unique needs and goals for problem resolution. Psychotherapy, as I practice it, is a partnership between client and therapist with the purpose of alleviating distress in one s sense of emotional well being, relationships, and work or school life. The goals of therapy are to alleviate emotional stress through understanding, support, and reassurance, and to promote personal growth and insight. My therapeutic orientation is based on client-centered psychology, focusing on bringing awareness to thoughts and behaviors and focus on building inner strength for problem resolution toward living a balanced life. Treatment generally consists of verbal explorations of your thoughts and feelings as they occur both inside and outside of the therapy sessions. I am trained in, and offer a variety of effective treatment techniques and interventions including talk therapy, cognitive behavioral therapy, trauma therapy, meditation, guided imagery, awareness exercises, emotional regulation and distress tolerance skills and play therapy. The specific treatments utilized will be aimed to meet your varied immediate and long-term goals. The typical process of therapy includes an assessment, establishing a treatment plan which includes specific short-term and long-term goals, and then on-going therapy lasting several weeks to several months depending upon your specific needs. While I may guide the discussion in ways aimed at problem clarification and resolution, it is your responsibility as the client to discuss what treatment method best works for you. Therapy also has potential emotional risks including the possibilities of worsening symptoms and disruptive life changes. Approaching feelings or thoughts that you have tried not to think about for a long time may be painful. Making changes in your beliefs or behaviors can be scary, and sometime disruptive to the relationship you already have. You may find your relationships with me to be a source of strong feelings. It is important that you carefully consider whether these risks are worth the benefits to you of changing. Most people who take risks find that therapy is helpful, and I will do what I can to help you minimize risks and maximize positive outcomes. While it is your choice to opt out of treatment at any time I encourage you to bring your thoughts to my attention so we the risks of any abrupt termination of treatment can be discussed. There are occasions in therapy where I may need to seek consultation to gain greater insight and feedback for my work. Should I consult on my work with you, I will not use your name or any information that can identify you. Should I need to refer you to another professional more qualified to help you (e.g. traditional or non-traditional practitioner, another therapist, educational specialists, etc.), I will discuss the idea with you prior to taking action. 1

Mary Peters, MA, LMHC Please note that my goal is to improve the mental health of my client. In this role, I am not available to make parenting evaluations, custody recommendations or expert witness or testimony. While I am specially trained to help children, teens and adults to overcome the traumas of sexual abuse, I do not make determinations of sexual abuse or domestic violence. Education and Experience Master Degree in Clinical Psychology, Antioch University, Seattle, WA, 2004. Washington State Licensed Mental Health Counselor and certified Child Mental Health Specialist. Bachelor of Arts, Organizational Management, Central Washington University, Ellensburg, WA, 1997. 20 years experience in career counseling and executive management consulting as a corporate Human Resources Director. My background includes, but not limited to, extensive training and experience in treatment of children, adolescents and adults with sexual abuse and other traumas, stress management, anxiety and depression, grief and loss, and self-esteem issues. I also have extensive experience in career coaching and helping adults with work/life issues. Fee Information and Payment Policies Fees are based on a 50-minute counseling session. The normal fee for individual therapy is $140.00 per session with cash discount prices available if you are paying out of pocket. Phone calls beyond regular scheduling issues lasting longer than 10 minutes are subject to my hourly fees. Letters, consultations, reports, and travel time are also billed at the same hourly rate. Any court related activities including but not limited to depositions, court, and travel time will be charged at the rate of $250.00 per hour. Payment in the form of cash, check, Visa or Mastercard is expected at the time of the scheduled appointment. A sliding scale based on household income is available when there are financial constraints. I regret the necessity of assessing a $20.00 charge for returned checks and utilizing a collection agency to recover any unpaid balances 60 days or more. Any overdue bills will be charged 1.5% per month interest. Please note the importance of contacting me within 30 days of your statement date if you challenge a billing charge. After 30 days, you accept the charges as correct. Insurance and Managed Mental Health Care Most insurance companies cover mental health services at a rate of 50 80% for a specific number of sessions. Be sure to call your health insurance company and research eligibility for coverage and benefits prior to our first session. If your health insurance plan does cover my services, I will work with your insurance company directly for billing and you will be responsible for any co-pay, co-insurance and/or deductibles at the time of service. Should you choose to utilize your insurance benefits for mental health services for reimbursement, please be aware insurance companies may require therapist notes to justify or limit coverage. Because of the tendency to share information, your confidentiality is seriously compromised. In addition, I will be required to submit a diagnosis based on the Diagnostic and Statistical Manual (DSM-IV). Diagnoses are technical terms that describe the nature of your issues and whether they are short-term or long-term problems. If I do use a diagnosis, I will discuss it with you. This diagnosis becomes a permanent part of your medical record and may affect your ability to qualify for disability or life insurance at a later date. 2

Mary Peters, MA, LMHC Office Hours and Appointments My office is open by appointment only between the hours of 10:00 a.m. and 7:00 p.m. Monday through Fridays. To schedule, cancel, or reschedule an appointment, please call or leave a message at 206-200-3957. I routinely check messages and return phone calls Monday thru Friday until 7 p.m., please note I do not check messages or return calls on the weekend. Sessions are generally scheduled weekly, but may be scheduled more or less frequently depending on your circumstances. Please note that when you schedule an appointment, that time is specifically reserved for you. In the event that you need to cancel or reschedule your appointment please notify me 24 hours in advance. If you cancel an appointment with less than 24 hours notice, you will be billed for the full hourly rate for the unfilled time. Missed/No Show appointments will be billed at the full hourly rate as well. Emergencies Because this is a non-medical practice, I may not always be available for after-hours consultation. You may leave a message on my voice mail I will make every attempt to respond to your needs. I understand your need for emergency help and for after-hours support. Please be aware that this time will be subject to a higher hourly rate. In the case of a life threatening emergency (such as plans for suicide, intentions to harm self or others, serious medication side effects, chest pains, shortness of breath, paralysis, etc.), call 911 or go to the emergency room. If you are in crisis and in need of support call the Crisis Clinic for assistance and advice (King County Crisis Clinic 206-461-3222, Snohomish County Crisis Care 425-258-4357). Do not wait for me to call you back if you are having an emergency. Electronic Communication and Social Media Policy Email and Texting If you choose to communicate with me via email or texting please be aware these are not completely secure or confidential as both are retained in logs of your and my internet service providers or may be read by unauthorized friends or family if your devices are not security protected. While my electronic devices are password protected and have firewalls I am unable to guarantee confidentiality, therefore, I only accept emails or text messages regarding scheduling issues. Email and texting are NOT appropriate means to use as an adjunct to therapy or contacting me during times of crisis. Please be aware emails and text that are clinically significant become part of your clinical record. I do my best to check my email and text throughout the day if I do not respond to your email or text within 24 hours (with exception of weekends) please contact me via phone at 206.200.3957. Friending I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that 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 to talk more about it. Business review sites You may find my psychology practice on sites such as Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses. Some of these sites include forums in which users rate their providers and add reviews. If you should find my listing on any of these sites, please know that my listing is NOT authorized by me nor is it a request for a testimonial, rating, or endorsement from you as my client. The American Psychological Association s Ethics Code states under Principle 5.05 that it is unethical for psychologists to solicit testimonials. Of course, you have a right to express yourself on any site you wish. But due to confidentiality, I cannot respond to any 3

review on any of these sites whether it is positive or negative. I urge you to take your own privacy as seriously as I take my commitment of confidentiality to you. You should also be aware that if you are using these sites to communicate indirectly with me about your feelings about our work, it is probable that I may never see it. If we are working together, I hope that you will bring your feelings and reactions to our work directly into the therapy process. This can be an important part of therapy, even if you decide we are not a good fit. None of this is meant to keep you from sharing that you are in therapy with me wherever and with whomever you like and are more than welcome to tell anyone you wish that I m your therapist or how you feel about the treatment I provided to you, in any forum of your choosing. If you do choose to write something on a business review site, I hope you will keep in mind that you may be sharing personally revealing information in a public forum. I urge you to create a pseudonym that is not linked to your regular email address or friend networks for your own privacy and protection. If you feel I have done something harmful or unethical and you do not feel comfortable discussing it with me, you can always contact the Board of Psychology (listed below) which oversees licensing, and they will review the services I have provided. Electronic PHI I use Office Ally, an online billing clearinghouse to process most insurance billing and an independent contractor for bookkeeping purposes. Both have signed business associate business contracts and have HIPAA Notice of Privacy Policies. All PHI information stored on my computer is encrypted and password protected for security purposes. Confidentiality I am bound by my professional ethics to protect client rights to confidential communications regarding their involvement in counseling. Minors If you are a patient under 18 years of age and not emancipated, your parents have the right to examine your treatment records. Since privacy in counseling is often crucial to successful progress, particularly with teenagers, it is common that I request an agreement from the parents that they consent to give up access to their child s records. If they agree, I will provide them only with general information about your progress in treatment, and your attendance at scheduled sessions. Any other communication will require the your authorization, unless I feel that the you are in danger or is a danger to someone else, in which case I will notify your parents of my concern. Before giving parents any information, I will discuss the matter with you, if possible, and I will do my best to handle any objections you may have. Your right to confidentiality has the following exceptions as provided by law: 1. In the event of a medical emergency, emergency personnel or services provided may be given the necessary information. 2. In the event of a threat of harm to oneself or someone else, if that threat is perceived to be serious, the proper individuals must be contacted. This may include the individual against whom the threat is made. 3. In the event of suspected child or elder abuse, the proper authorities must and will be contacted. The actions or events do not have to be witnessed or reported. 4. If ordered by a judge or other judicial officers, information regarding your treatment may be disclosed. 5. If you bring a complaint against me with the State of Washington, Department of Health, information is required to be released. 6. If an attorney in the State of Washington subpoenas records, they will be released unless you file a protection order within 14 days of the subpoena. 4

Mary Peters, MA, LMHC Confidentiality, Continued. 7. In the event of the client s death or disability, the information may be released if the client s personal representative or the beneficiary of an insurance policy on the client s life signs a release authorizing disclosure. 8. In the event the client reveals the contemplation or commission of a crime or harmful act, the therapist may release the information to the appropriate authorities. 9. In the case of a minor client, information indicating that the client was a victim of a crime may be released to authorities. Review of Records Records of the health care services I provide you are kept in a secured location in my office. You have the right to see and copy these records and/or make any corrections. You may also request that I make a copy of your file available to any other health care provided at your written request. I may charge a reasonable fee for photocopying. Ethics and Standards As a therapist I am committed to following the code of ethics as defined by the American Psychological Association and the professional standards of the State of Washington counselor licensing law (WAC 246-810 and RCW 18.130.180). Counselors practicing for a fee must be registered or certified with the Department of Dealth for the protection of the public health and safety. Registration of an individual with the department does not include recognition of any practice standards, nor necessarily imply the effectiveness of treatment. The law that regulates counselors is called the Counselor Credentialing Act. The purpose of this law is to provide protection for public health and safety and to empower the citizens of the State of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct. Questions of complaints may be directed to: Dept. of Health, Business and Professional Administration P.O. Box 9012 Olympia, WA 98504-8001 (360) 753-1760 Washington State law provides that as a consumer you have the following rights and responsibilities: 1. You have the right to be treated with respect and dignity. 2. You have the responsibility to develop a plan of care and service which meets your unique needs. 3. You have the responsibility of choosing the provider which best suits your needs. 4. You have the right to refuse any proposed treatment and to discontinue treatment at any time, with our without notice to the treatment provider. 5. You have the right to receive care that does not discriminate against you, and is sensitive to your gender, race, national origin, language, age, disability, and sexual orientation. 6. You have the right to be free of sexual exploitation or harassment. 7. You have the right to review your case record. 8. You have the right to receive an explanation of all medications prescribed, including expected effect and possible side effects. 9. You have the right to confidentiality. 10. You have the right to lodge a complaint or grievance with the ombudsperson, RSN, or this therapist if you feel your rights have been violated. If you lodge a complaint or grievance, you shall be free of any act of retaliation. 5

Mary Peters, MA, LMHC, PS, Inc. 631 5 th Street, Suite 201 Mukilteo, WA 98275 Client Agreement If you have any questions regarding the information you contained in my personal disclosure statement, please feel free to discuss them with me now, or anytime in the future. I have been provided a copy of the required disclosure information and have read and understand the information provided including my rights as a client. My decision to work with my therapist includes a consent for treatment and a willingness to abide by these guidelines and part of my commitment to receiving the help I requested. I have received and read the Notice of Privacy Practices and understand my rights regarding protection of my Protected Health Information (PHI). I have read the Electronic Communication Policy and understand the confidentiality vulnerabilities of using electronic communication. I would like the option to use email and/or texting as a form to communicate scheduling needs and understand it is not appropriate to use as an adjunct to therapy or if in crisis. I chose not to use email or texting as a form of communication. I have agreed to be responsible for a counseling fee of $ (per 50 minute session) to be paid at each counseling session. I understand the cancellation policy and agree to pay your hourly rate for missed appointments or if cancelled less than 24 hours notice. Thank you for taking your time to read the required documentation, I welcome you as a client and look forward to our work together! Client Signature Date Parent/Guardian Signature Date Mary Peters, MA, LMHC, PS, Inc. Date 6