Counselor Disclosure Statement
Welcome! I’m so glad that you are here. As a Mental Health Counselor Associate, Washington State Law (WAC 246-810-031) requires me to provide written disclosure of the following information to clients before beginning services. This document is designed to inform you about what you can expect from me regarding confidentiality, emergencies and several other details regarding your treatment. Please know that your relationship with me is a collaborative one and I welcome questions, comments or suggestions regarding your course of therapy at any time.
Confidentiality Let me begin by emphasizing that what you tell me is legally protected and strictly confidential. I will not share any information I know about you to anyone without your prior written permission. Information you share with me may be entered into your records in written form. You will be provided with a copy of my Privacy Practices Notice, which gives more detail about your rights to confidentiality. In most circumstances, information in your records can be released only if you specifically authorize it in writing. The following list tells you when confidential information may be released to others without your consent:
1) I am required by law to report information about child abuse/neglect or elder abuse/neglect. (Washington Law RCW26.44)
2) If you threaten to harm yourself or someone else, and I believe your threat to be serious, I am required by law to take whatever actions necessary to protect you or others from harm.
3) If you are involved in litigations of any kind and inform the court of the services you received from me (making your mental health an issue before the court), you may be waiving your right to keep my records confidential. I may be required to disclose your health information if a court issues an appropriate order. Please consult your attorney for clarification.
4) Information that may jeopardize my safety will not be kept confidential.
5) In the event of a medical emergency, emergency personnel may be given necessary information.
6) If you bring a complaint against me information will be released.
7) In the event of a 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.
Your Rights You have the right to choose a counselor who best suits your needs and purposes. If at any time you are uncomfortable with the direction counseling is taking you have the right to discuss this with me so that we can make adjustments. This might include a change of counseling approach, a referral to another counselor, or discontinuing counseling. You also have the right to ask about other treatments for your condition and their risks and benefits. My Notice of Privacy Practices provided at intake informs you of HIPPA, a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Heatlh Information (PHI) used for the purpose of treatment, payment and health care operations. If you wish to complain about any improper conduct you can call the state Department of Health, Health Professions Quality Assurance Division, PO Box 47869, Olympia WA 98504. Please read the attached HIPPA Privacy Notice about additional rights you have.
Supervision In accordance to WAC246-810-025, supervision is a forum used by supervisees to reflect on all aspects of their work, where they receive formal and informal feedback on that work, and where the welfare of clients and the quality of the service they receive is central for a total of 100 supervision hours. As a Licensed Mental Health Counseling Associate, I am supervised by Hannah Smith, LMHC, CGP, licensed mental health counselor in Washington (LH00010370). I also participate in peer review and case consultation with other professional therapist. I consult with other therapists regarding my cases because I believe our collective knowledge may help me provide you the best counseling services possible. I do not disclose names or details that would allow identification of my clients during these processes.
Legal Information The Department of Health requires that you are informed that “Counselors practicing counseling for a fee must be credentialed with the department of health for the protection of the public health and safety. Credentialing of an individual with the department of health does not include a recognition of any practice standards, nor necessarily imply the effectiveness of any treatment.”
Education, Training & Background Experience I completed a Master of Science degree in Educational Rehabilitation Counseling at University of Wisconsin-Milwaukee 1998 and a Bachelor of Science in Psychology from Corban University in Salem, OR. I have over 25 years of experience in areas of counseling, case management, crisis counseling, vocational counseling, brain injury rehabilitation, mental health counseling, disability consultant and family therapist. I’ve worked in both private and public sector as a rehabilitation counselor. I have lead several different group sessions for relaxation, mindfulness, social training, connectedness, DBT, cognitive/behavioral strategies and experience working with grief and loss. I’ve completed training in coaching, communication, counseling children and adolescents, strategies with angry, oppositional, defiant kids, and completed course in undoing institutionalized racism.
My therapeutic approach focuses on a holistic, whole-person approach that is relational and client-centered. My approach involves the consideration of your whole being, including your feelings, spirituality, stage of life, relationships, and health. I often use techniques of Cognitive Behavioral Therapy, Biofeedback, Neurofeedback, Dialectical Behavior Therapy, person-centered and solution focused strategies. I have a warm, empathetic style that is non-judgmental and genuine. My goal is to provide counseling within a safe, comfortable environment listening to experiences, building trust in order to help resolve concerns, and improve relationships. I want clients to discover their real self, while challenging them at the same time helping them learn to manage anxiety, depression, relationships, personality traits and life stressors.
Risks and Benefits Counseling, psychotherapy and biofeedback, when engaged in as a process, are beneficial. However, as with any treatment, there are inherent risks. During counseling, you will discuss personal issues, which may bring up emotions such as anxiety, anger, guilt, and sadness. This can be uncomfortable. In addition, you will be asked to do work outside of your comfort zone. That said, every effort will be made to control pacing and not to overwhelm or overload. Your feedback regarding this is greatly encouraged all along the way.
The benefits of counseling can far outweigh any discomfort encountered during the process. Some of the possible benefits are improved personal relationships, reduced feelings of emotional distress, and gaining of specific problem-solving skills. There are no guarantees, of course, but it is my goal is to create a safe environment where together we develop a treatment plan, and work to achieve your goals. This may include referrals to other providers.
Minors & Parents In the State of WA, minors have the right to confidentiality at the age of 13. This means parents do not have the right to access the minor’s counseling records or conversations between therapist and child unless I have written authorization from the minor. I do not perform parenting or custody evaluations. I am not available to testify or provide forensic evidence in custody cases. I do not investigate child abuse/neglect issues, but I am legally mandated to report suspected abuse/neglect.
Marriage/Couples Counseling If you are receiving marriage or couples counseling, anything you say to me in one-to-one conversations will not be considered confidential from your partner. If a legal case emerges, confidentiality may be jeopardized. Both parties must sign an Authorization for Release of Information in order to release any records to one or both parties. I am not available to testify or provide forensic evidence on behalf of one or the other counseling participants.
Phone Calls and Emergencies Should you need to contact me between visits, you may call and leave a voice mail. I will make every effort to return your call within 1-2 business days, if not an emergency. My office voice mail is confidential and the messages are only heard by me. If you are experiencing a life-threatening emergency please call 911. If you are experiencing a psychiatric emergency or crisis and I am not available, Crisis Responders can be reached 24/7 at Snohomish County Crisis Services at (425) 388-7215 or toll-free (800) 584-3578.
Electronic Communication Be advised that the use of email, cell phone texting, and other forms of technology may have security concerns and have not been defined as a best-practice strategy. Any information exchanged electronically or with the use of technology increases the risk of confidentiality breaches. Communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed. Therefore, it cannot guarantee protection from unauthorized attempts to access, use, or disclose personal information exchanged electronically. Do not include personal identifying information such as your birth date, or personal medical information in any emails you send. Email/texting communication with NW Skyline will be used for the purpose of simplifying and expediting scheduling/ administrative matters only. You should also know that any electronic communication I receive from you and any responses that I send to you may become a part of your legal medical record. Email/text communication is NOT to be used to provide/receive treatment services or take the place of therapy sessions.
Appointments, Billing Policy and Fees Your appointment, which lasts about 50 minutes, has been scheduled exclusively for you. Payment is due at the time of service in the form of cash, check or credit cards via an app. Please note there is a $3.00 fee for each credit card transaction. Checks can be made payable to “NW Skyline”. I do not bill insurance nor take insurance. My fees are as follows:
Initial Consultation 50-minute Therapy Session……………………………… $150.00
50-minute Therapy Sessions .......................................................................$130.00
45-50 minute Biofeedback Session…………………………………………….$150.00
Low Level Light Therapy…………………………………………………………$ 40.00/session
No Show Fees (less than 24-hour cancellation) ..........................................$100.00
Phone Calls/Letter Writing (10-day notice required) …………………………$ 20/quarter hour
Terminating Treatment My goal is to assist you in obtaining your desired therapeutic outcomes. If you have any questions or concerns about any aspect of your therapy, please discuss them with me. If you elect to terminate or suspend treatment, please discuss your decision with me so that we can bring sufficient closure to our work together. In our final session we can discuss your progress thus far and explore ways in which you can continue to utilize the skills and knowledge you have gained through your therapy. We can also discuss any referrals that you may require at that time.
Telehealth Options “Telehealth” includes the practice of health care delivery, diagnosis, and treatment consultation using interactive video, audio,and/or data communications. For Telehealth sessions, we will be connecting using Doxy (most often) or Zoom, which is a system that is encrypted to the federal standard and HIPAA compatible. As your therapist, I will ensure that my telehealth system is set up in a place that is confidential and as free from distraction as possible. It is your responsibility to choose a secure location to interact with technology-assisted media and to be aware that family, friends, employers, co-workers, strangers, and hackers could either overhear our communications or have access to the technology with which you are interacting. Additionally, I agree not to record any TeleMental Health sessions. During a TeleMental Health session, we could encounter a technological failure. The most reliable backup plan is to contact one another via telephone should you struggle to connect or run into any disconnections during the session. My phone number for this is (425) 318-4353. I will ensure that I have a phone with me whenever we meet. All fees for Telehealth and non-Telehealth services are the same. You are financially responsible for all services rendered, late cancellations, and missed appointments. 24-hour notice of cancellation to avoid no-show fee still stands for telehealth services.
Independent Contractor in Health Clinic I conduct my counseling as an independent practitioner in a health clinic. Given this, I share a common waiting room with other practitioners.
Please sign below to indicate that you have fully read and agree with all that was stated in this document and are consenting to services. I agree to pay for therapy as outlined in this disclosure statement. My signature below indicates that I understand and agree to the conditions of therapy provided in this disclosure statement.
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Client Printed Name
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Client Signature Date
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Denise Ibrahim, MS, LMHCA Date