Informed Consent

CLIENT-COUNSELOR SERVICE AGREEMENT


This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is particularly important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.


Welcome to my practice! I received my bachelor’s degree from Seattle University in Social Work, with a certification in Diversity, Citizenship and Social Justice in 2009. After that, I went on to the University of Washington where I received my master’s degree in Social Work, specializing in mental health.


I am bilingual in Spanish and English and bi-cultural. I am currently registered with the state of Washington as a Licensed Independent Clinical Social Worker (#LW60672340). I have worked with families and youth since 2007. Before that I worked in social health field as a certified nursing assistant, in both residential and private homes. Since 2007 I have worked in multiple nonprofits across King County as a mental health therapist, bi-lingual counselor in a residential home for tennage boys, mental health case manager, career navigator, camp counselor, and camp director.


Counseling is a relationship between people and that works in part because of clearly defined rights and responsibilities held by each person. 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 counselor, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

 


GOALS OF COUNSELING

There can be many goals for the counseling relationships. Some of these will be long term goals such as improving the quality of your life, learning to live with mindfulness and self-actualization. Others may be more immediate goals such as decreasing anxiety depression symptoms, developing healthy relationships, changing behavior or decreasing/ending drug use. Whatever the goals for counseling, they will be set by the clients according to what they want to work on in counseling. The counselor may make suggestions on how to reach that goal but you decide where you want to go.

 


RISKS/BENEFITS OF COUNSELING

Counseling is an intensely personal process which can bring unpleasant memories or emotions to the surface. There are no guarantees that counseling will work for you. Clients can sometimes make improvements only to go backwards after a time. Progress may happen slowly. Counseling requires an active effort on your part. To be most successful, you will have to work on things we discuss outside of sessions.


However, there are many benefits to counseling. Counseling can help you develop coping skills, make behavioral changes, reduce symptoms of mental health disorders, improve the quality of your life, learn to manage anger, learn to live in the present and many other advantages.


APPOINTMENTS


Appointments will ordinarily be 50 minutes in duration and can range from once a week to once a month, as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours’ notice. If you miss a session without canceling, or cancel with less than 24-hours’ notice, you will be required to pay the session [unless we both agree that you were unable to attend due to circumstances beyond your control. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the cancellation fee. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.


If you have one or more late cancellations/no shows, we will revisit if we are a good fit for each other, or if this is the right time for you to enter a therapeutic relationship. I reserve the right to cancel/terminate your counseling if there appears to be a continuation of late cancellations/no shows. You will be charged for all late cancellations/no shows, and in order to continue or reschedule your appointment, you will need to pay the pay the late fee in order to proceed.

 


CONFIDENTIALITY


I will make every effort to keep your personal information private. If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality to which you need to be aware. Your counselor may consult with a supervisor or other professional counselor to give you the best service. If I must consult with another counselor, no identifying information such as your name would be released.


Counselors are required by law to release information when: 

  • If I feel you pose a risk to yourself or others.

  • If I suspect abuse to children or the elderly.

  • If your I receive a court order or subpoena, I may be required to release some information. In such a case, I will consult with other professionals and limit the release to only what is necessary by law.

  • If you are submitting forms to your insurance. At times they will require me to submit additional information such as your diagnosis.

 

CONFIDENTIALITY AND TECHNOLOGY


Some clients may choose to use technology in their counseling sessions. This includes but is not limited to online counseling via Skype, telephone, email, text, or chat. Due to the nature of online counseling, there is always the possibility that unauthorized persons may attempt to discover your personal information. I will take every precaution to safeguard your information but cannot guarantee that unauthorized access to electronic communications could not occur. Please be advised to take precautions regarding authorized and unauthorized access to any technology used in counseling sessions. Be aware of any friends, family members, significant others or co-workers who may have access to your computer, phone or other technology used in your counseling sessions. Should you have concerns about the safety of your email, please discuss them with me. Please note that my email is encrypted.

 


FEES


You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check or cash. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment.


If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required.


Fees are non-negotiable. To receive sliding scale fees, you must present proof of income through recent pay stubs or tax forms. Fees are subject to change at a counselor’s discretion. The regulate rate for a 50-minute session is $135 – this does not include the initial assessment. Any phone calls under 10 minutes will not be charge, unless they become a pattern then we will need to address this. Any phone conversations over 10 minutes will be billed at a prorated rate of the normal rate of $135. Any work outside of our sessions, will also be billed at the regular rate; this includes school visit, court, and consultations with other providers.


If you are on a sliding fee, please note that any last-minute cancellation or no-show fee will be billed at the normal rate of, $135 an hour.

 


INSURANCE


I am not accepting insurance, unless it is through your EAP that I am contracted with, such as LYRA and Wellsprings.


Payment types that I accept are:

  • All major credit cards.

  • Check

  • Cashier Checks

  • Money Orders

  • HSA/FSA

  • Cash


I use IVY Pay to charge all cards, which is HIPAA complaint, keeping your information confidential.

 


CONTACTING ME


I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a brief message on my voicemail. Please note that it is not a confidential voicemail, so please do not leave identifying information. If you feel you cannot wait for a return call or it is an emergency, go to your local hospital or call 911 or our local 24 Hour Crisis Line at 206.461.3222.

 


EMAIL


There are times that email communication might be a better form of communication, so I may request your email. You have the right to refuse to divulge your email address. There are times that I may send newsletters or periodically check in with clients.

 


CONSENT TO COUNSELING


Your signature below indicates that you have read this Agreement and agree to its terms, and I understand that I have the right to terminate therapy at any time.