AGREEMENT FOR TREATMENT AND INFORMED CONSENT

Please correct the errors described below.

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Dialogical Therapy, PLLC, dba Open Dialogue Pacific Alita Kathryn Taylor, MA, LMFT & Fletcher Taylor, MD, MFA 2706 North Warner Street, Tacoma, WA 98407 2101 4th Ave #370, Seattle, WA 98121 Phone: 253-212-3101 FAX: 253-212-3225

Please read each section and sign where applicable.

AGREEMENT FOR TREATMENT AND INFORMED CONSENT

Successful therapy is only possible if the therapist and the client work together. Open Dialogue Pacific is dedicated to achieving the best possible results for its clients. As a general rule, although no particular result can be guaranteed, informed and cooperative clients are more likely to achieve positive results. Please read the following information carefully. We welcome the opportunity to discuss any questions or concerns you may have regarding this agreement or our services at any time. If you have any questions about anything in this Informed Consent, please discuss it with us prior to starting treatment and immediately when questions arise during treatment.

CURRENT PRACTICE:

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Our practice focuses on treating families, couples, groups and individuals. We are experienced with GLBTQ populations, adolescents, couples, family members of those with addictions, those with addictions themselves, those caregiving for dying or ill family members, and those experiencing dying themselves. We have specialized training in working with families and social networks surrounding a person in crisis, including those with what-some-may-call psychosis. We practice dialogically, which portends that every position in a family or in a couple has a voice and a perspective that is both important and unique from all the others. Allowing and hearing all the voices is a tenet of dialogical practice. Conversations that emerge in therapy are infinite in possibility. We are all relational beings and our engagement with the world is in endless motion. In dialogical practice, the mystery and awe of each person’s creative way of problem-solving and each dynamic relationship in their social or family network is held. Dialogical therapists allow lots of space, silence, and reflection in sessions, intuiting the natural inner intelligence and capacity of each relationship and person to find their way. We carefully witness, listen, and actively attend to each family’s style. We reflect the client’s goals, focusing on strengths, helping facilitate dialogue around current, immediate needs. Both of our therapists, Alita and Fletcher, are educators. Alita is a trainer of psychotherapists in Open Dialogue, the public mental health model for treating what-some-may-call-psychosis and other crises which has been studied and practiced in Northern Finland since the 1980s. Open Dialogue is (1) inclusive (i.e., client-/family-/social network-centered,) (2) collaborative (i.e., multiple professionals are present at sessions), (3) flexible and mobile (i.e., sessions vary in length and frequency adapted to the person and their extended support system), and (4) community-based. Philosophically, we treat people, not diagnoses. We envision Open Dialogue becoming standard practice as it is evidence-based, cost-effective, and humanistic. Many countries are adapting Open Dialogue to the way psychiatry is practiced. Currently, it is an emerging practice in the U.S. for families and what-some-may-call-early psychosis. In addition to his private practice, Fletcher is a clinical associate professor at the University of Washington, currently specializing in preparing medical residents in the up-and-coming psychiatric treatment modalities.

METHODS OF TREATMENT AND APPROACH TO THERAPY:

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Our philosophy is that you are the expert of you. Often patterns and behaviors appear for very good reason, even though they may seem new or maladaptive, they can also be a sign of growth. Perhaps you are feeling what you are feeling as a result of societal/systemic distress, historical or familial trauma. Your current situation could be a very important signal that change is desired in some way, just like in nature and in the seasons. The only constant in life is change. The root of “psyche” (as in psychologist or psychotherapist or psychiatrist) means “soul,” and the root of “ logist” is “word” or “breath.” In a way, we view our job to be a “minister to the breath of life.” We consider it a great honor and a privilege to sit with people during times of grief, loss, change, wonder, and/or difficulty. Relationships are often tremendous tools for pushing us where we’d never go alone. We respect diversity in our practice, and therefore your cultural and spiritual values and beliefs are of utmost importance to us in our work. If we have your consent (and that of each person in a therapy session), we videotape sessions for the purpose of seeing ourselves to better our practice as psychotherapists. We have a peer group with whom we review these videotapes together in consultation for the purpose of providing feedback but will not otherwise share these session tapes.

CHANGE IN TREATMENT:

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You always have the right to request a change in treatment or to refuse treatment. It is essential that you are comfortable that what we do together meet your needs. If you believe you are not getting the help you need, please tell us so that we can work through that together. If we are unable to do so to your satisfaction, we will assist you in finding another therapist. In the event it is necessary or advisable for you to seek care from other therapist(s) or professional(s) during, after, or as a result of our therapy treatment, all costs and expenses associated with such treatment are your responsibility and will not be included in the costs of your treatment with us.

CONFIDENTIALITY:

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In some cases, it may be useful to the therapy to discuss your situation with others, such your primary care physician, former therapist, a teacher, a referral source, etc. In those cases, we will seek your permission for this exchange of information by obtaining a written “Release of Confidential Information.” Except as required by law or court order (which may include your threat of imminent harm to an identifiable victim, suspicion of child, elder, or dependent adult abuse, and/or suspicion of danger to self), we will not exchange or release confidential information without your consent. Written permission to discuss your case with other healthcare professionals is not necessary in all situations. On occasion, we will consult with colleagues about our work with a particular client to gain feedback and suggestions about treatment, but we will not share clients’ names or unique information in such consultations. Please ask for and sign our “Verbal/Written Permission Form” within which you can detail with whom and how you would like us to communicate with others involved in your care.

APPOINTMENTS:

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Your appointment time is held exclusively for you. Please arrive on time. If you miss an appointment or do not cancel it at least 24 hours before the scheduled time, you will be charged for the appointment. Insurance does not reimburse for missed sessions, so you agree to make the full payment for any missed appointments. If you fail to pay this fee, you will be subject to dismissal from future services through Dialogical Therapy, PLLC until your account is made current.

TELEMEDICINE:

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In our practice, we engage in providing therapy services through telemedicine technologies which include, without limitation, the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, data and other electronic communications, including email, texting, and apps, between the therapist and the client who are not in the same physical location. During telemedicine therapy details of your medical history and personal information may be discussed with you. It is your responsibility to maintain privacy on your end of any communications, and to take the necessary precautions to ensure that all communications are directed only to your therapist or to our office. Telemedicine may also involve the communication of your medical/mental health information, both orally and visually, to health care practitioners located in and/or outside Washington. The laws that protect the confidentiality of your medical information also apply to telemedicine, subject to mandatory and permissive exceptions to confidentiality, including without limitation, reporting child, elder, and dependent adult abuse, expressed threats of violence toward an ascertainable victim, and where your mental or emotional state are subject to a legal proceeding. There are risks and consequences from telemedicine, including, without limitation, the possibility, despite reasonable efforts on our part, that the transmission of our services and/or your medical information could be disrupted, distorted by technical failures, or be interrupted or intercepted by unauthorized persons, and/or the electronic storage of your medical information could be accessed by unauthorized persons. In addition, telemedicine-based services and care may not be as complete or efficient as face-to-face services. We reserve the right to provide our services via telemedicine or to suggest that you may benefit from telemedicine. As with other forms of delivery, the results of providing services by telemedicine cannot be guaranteed or assured. If, during your treatment, your therapist believes you would be better served by another form of psychological services (e.g. face-to-face treatment), you agree to pursue such alternative treatment with us or with another mental health provider. Further, if you wish to have your therapy sessions in-person rather than by use of telemedicine, it is your responsibility to inform your therapist of this desire and to schedule an in-person appointment with our office. You acknowledge that an appointment may not be immediately available in our office at any given time. You will need access to, and familiarity with, the appropriate technology in order to participate in telemedicine. By signing this Informed Consent, you agree to the use of telemedicine in our treatment. Further, you may withhold or withdraw this consent at any time without affecting your right to future treatment. You have the right to decline telemedicine therapy at any time without jeopardizing access to future care or services.

EMERGENCY CALLS:

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If you are at any time experiencing a medical emergency, please immediately call 911 or go to your nearest emergency room, but in the case of a mental health emergency related to your care under me, please call our office number to receive instructions on how to reach us, the clinician covering our practice, or a mental health crisis response line for help.

BILLING AND PAYMENTS:

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Fee payment is your responsibility. Please pay for services on time. If you are unable to manage this, please work out a payment arrangement with our office in advance. Ultimately you are responsible for your account and are expected to pay your bill, whether insurance pays for a portion or not. A late charge of 1% may be added to any balance not paid in 60 days after the charge is incurred. If 90 days pass without a payment, accounts may be sent to a collection agency. Payments received are applied to the earliest treatment provided. If you have questions about your account, please promptly call us.

INSURANCE:

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We are contracted providers with several insurance companies. Be sure to check with your insurance company and our office to confirm whether or not we are a provider for your plan. It is your responsibility to inquire if your insurance plan requires a preauthorization or a written PCP referral, if you have a separate annual deductible for mental health, and whether your mental health benefit has a maximum yearly number of sessions or a maximum yearly dollar amount. All copayments, deductibles, and payments for non-covered services are due at the time of your visit. We submit claims on your behalf. In order for this to occur you must complete Dialogical Therapy, PLLC’s intake billing and insurance release of information form. You will need to provide a copy of the front and back of your insurance card and your identification at your first appointment. Your agreement with your insurance carrier is a private one, and we do not routinely research why it paid less than anticipated for care. If your insurance carrier has not paid within 60 days of billing, professional fees are due and payable from you in full. Any care not paid for by your existing insurance coverage will require payment in full at the time services are provided or upon notice of insurance claim denial. Worker’s Compensation and Personal Injury cases (if applicable) will require motor vehicle PIP insurance and/or claim number and insurance carrier name, respectively. Please provide this to us at the time services are rendered.

CHANGES TO OFFICE POLICY:

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The policies for our practice may change from time to time. We will inform you of these changes either in writing, by email or text, verbally, or by posting them on our Website, www.opendialoguepacific.com.

RESULTS OF TREATMENT:

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We strive to take all reasonable steps to achieve the best results for every client. However, we cannot guarantee that you will be completely satisfied with the results of your treatment, nor can we anticipate all complications or consequences of treatment or the other alternatives to treatment. The success of treatment depends, among other things, on your cooperation in keeping appointments, you providing full disclosure of facts and circumstances affecting your situation, and you following our suggestions, advice, and our agreed-upon treatment plan. By signing this Informed Consent, you agree that there are potential risks and benefits associated with any form of therapy and that despite our best efforts, your condition may not improve, and in some cases may even get worse.

MISCELLANEOUS:

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We both agree that our intent is that the terms and conditions of this Agreement and Informed Consent constitute the complete, exclusive, and fully integrated statement of our agreement with respect to your treatment, that it supersedes and preempts any prior understanding, agreement, or representation, whether written or oral, and that, as such, it is the sole expression of our agreement. We both agree that any dispute regarding this Agreement and Informed Consent or the treatment provided will be governed by the laws of the State of Washington, without regard to conflict of law principles. Further if any action at law or in equity is necessary to enforce or interpret this Agreement, the prevailing party shall be entitled to reasonable attorneys’ fees and expenses in addition to any other relief to which such party may be entitled. The headings used herein are for convenience only and are not intended to describe, nor shall they be used to construe or interpret, this Agreement.

ACKNOWLEDGEMENT AND AUTHORIZATION FOR TREATMENT

I hereby acknowledge that I was given this Agreement for Treatment and Informed Consent prior to the commencement of my treatment by Dialogical Therapy, PLLC (the “Company”) and that I have read and fully understand the treatment considerations set forth in this Agreement for Treatment and Informed Consent, as well as those discussed with my therapist(s). I understand that there may be other issues that occur less frequently than those outlined, and that actual results may differ significantly from the anticipated results, and knowingly accept these risks. I acknowledge that I have disclosed all important matters related to my mental health with my therapist. I agree that my therapist and I have discussed this Agreement for Treatment and Informed Consent, the considerations associated with my treatment, that I have been given the opportunity to ask any questions I deem important, and that I have had such questions answered to my satisfaction. After careful consideration of the terms of my treatment, which I fully understand and accept, I hereby voluntarily consent to the treatment proposed and accordingly authorize the Company to provide therapy to me in person, using telemedicine, or in any manner deemed appropriate by any of the Company’s therapists. I further consent to the making of informational and diagnostic records, before, during, and following my treatment, and authorize the Company to provide other health care providers with information related to my treatment as deemed appropriate (which authorization may be revoked in writing by me at any time). I further understand and agree that once released, the Company, its therapists, its staff and representatives have no responsibility for any further release by the recipient of such information. I understand that my treatment fees cover only treatment provided by the Company and that treatment provided by other professionals, including without limitation, other therapists, is not included in the fee for my treatment. In addition, I acknowledge that any monies, including any advance payment, paid to the Company, are nonrefundable regardless of the outcome of my treatment or whether it is necessary, or I chose, to discontinue my therapy for any reason. I hereby give my permission for the use of my therapy records for purposes of professional consultations, research, education or publication in professional journals. I understand that I can withdraw my consent at any time by providing written notice of such withdrawal to the Company.

(Please type your full name here.)

In order for Dialogical Therapy, PLLC, to submit claims to your health insurance on your behalf your written consent is required. Please read and sign below if applicable:

I hereby assign all eligible medical benefits to which I am entitled, through private insurance and any other health plans, to Dialogical Therapy. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I understand I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure the payment.

(Please type your full name here.)

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Minor Clients – Legal Guardian Consent

The undersigned represents that he/she/they is/are the legal guardian of the client and has/have full authority to execute this informed consent and make the representations herein on behalf of the client.

(Please type your full name here.)

Acknowledged by Dialogical Therapy, PLLC Therapist (s)

Title: Member

Title: Member

After this document is received, Alita and/or Dr. Taylor will acknowledge and it will be placed together in your record. You may request a copy of this agreement at any time.

PATIENT/CLIENT REGISTRATION

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MEDICAL EXPENSES

If yes, please complete the following and please provide us with a copy of the FRONT and BACK of your insurance ID card(s) via email: admin@dialogicaltherapy.com or FAX (253) 212-3225 If no, you may skip to the next section "Obtaining Verbal/Written Permission" to use or disclose protected health information

PRIMARY AND SECONDARY INSURANCES (*Please provide us with the front and back of your insurance cards. Email to admin@dialogicaltherapy.com*) If you have Medicare, please also include your MediCare ID card.

IF APPLICABLE: LABOR AND INDUSTRIES CLAIM

I hereby assign payment directly to Dialogical Therapy for any treatment received. I agree that this authorization shall be valid until rescinded in writing or replaced by one of a later date. I agree to be financially responsible to Dialogical Therapy for all charges in the event that I have no insurance, if my insurance becomes inactive, or if any balance or fee is not covered by my insurance. If I fail to make sure Dialogical Therapy has received any new insurance information or if my insurance plan changes, I understand and acknowledge that if Dialogical Therapy files my insurance claim, I will remain responsible for the account and will be expected to pay any amount. I acknowledge that any amounts quoted as “out-of-pocket costs” are only an estimate and that the exact determination of my financial responsibility will be made after my insurance company processes the claim. Payment is expected at the time of service. Methods of payment accepted include check, cash and credit card (using HIPPA-compliant phone app Ivy Pay.) Financial responsibility is ultimately the guarantor for any balance not paid by the insurance company.

(Please type your full name here.)

(Please type your full name here.)

OBTAINING VERBAL/WRITTEN PERMISSION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION

How may we contact you with reference to your appointment, proposed treatment, follow-up appointments, billing question/problems and other situations regarding your protected health information? See below:

From time to time your practitioner may wish to use or disclose your protected health information to individuals involved in your care for notification purposes. As stipulated by the Title 45, Section 164.10, we are permitted to make such uses or disclosures after we have obtained your verbal or written permission.

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TEXT MESSAGE APPOINTMENT REMINDER AUTHORIZATION

I authorize Dialogical Therapy, PLLC to send appointment reminders electronically via text message to my mobile phone. I understand that this service is offered free of charge. However, standard text message rates from my mobile carrier may apply. Please activate text message reminders for my mobile phone number listed below.

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QUESTIONS REGARDING YOUR CURRENT NEEDS AND RELEVANT HISTORY

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THERAPISTS' CREDENTIALS

ALITA KATHRYN TAYLOR, MA, LMFT

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Alita received a Master of Arts in Clinical Psychology with an emphasis in marriage and family therapy from Pepperdine University Graduate School of Education and Psychology in Culver City, California, USA in 1995. Her experience has included work in multiple agency and hospital programs, including locked and unlocked residential, community, and private outpatient settings since 1992. Alita worked in emergency psychiatry from 2005-2017, and managed her own practice as a licensed clinician since 2006. Alita is a Licensed Marriage and Family Therapist (LMFT) in the State of Washington (#60785809) and in the State of California (#43665). She ascribes and adheres to the ethical and professional standards of State, Federal, and international certification requirements for family therapists. Her clinical memberships include: the California Association of Marriage and Family Therapists (CAMFT) since 2004, the Washington American Association of Marriage and Family Therapists (WAMFT/AAMFT) since 2017, the Family Systems Therapists of the Northwest (FSTNW) since 2018, the American Family Therapy Academy (AFTA) since 2018, and the Association of Family Therapists of Northern California (AFTNC) since 2020. Alita has certification, education, and personal experience in grief, death, and dying. She has taken specialized coursework in death midwifery, lament practice, and has co-facilitated family sessions at bedside with her husband, Fletcher B. Taylor, MD, who performs competency evaluations surrounding death and dying issues, combining medication-assistance with family psychotherapy. Alita holds a specialized certification to supervise and train professionals in couple and family dialogical practices, earned under Jaakko Seikkula, PhD, primary developer of Open Dialogue, at Dialogic Partners in Finland in cooperation with the University of Jyväskylä (2018.) She is in the International Collaborative-Dialogic Practices (ICCP) program (2019-2021) co-sponsored by the Houston-Galveston and Taos Institutes. She co-leads family sessions with other professionals, supervises, and consults. In 2019, Alita began formal study as a Dance Movement Therapist (DMT) through the American Dance Therapy Association (ADTA.)

FLETCHER B. TAYLOR, MD, MFA

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Dr. Taylor has lived and worked in Tacoma, Washington as a psychiatrist since 1990, and believes strongly he is a member of a community that includes, “all of us.” He divides his professional time between clinical practice, teaching, and research. He and his wife Alita often see clients together with their family/social network members. The elements leading to good health often fold in one’s family, one’s community, and one’s culture, in addition to traditional Western medicine. Dr. Taylor works from this framework and uses available resources that you choose. His published research includes work with anxiety/depression, learning disabilities, trauma-related issues, and sleep physiology. Dr. Taylor often finds new mental health treatment using existing medications: - A long-acting form of guanfacine has received FDA approval for attention deficit disorder. - Prazosin (used to treat high blood pressure) shows promise in the treatment of PTSD-related issues. His titles include: MD (Medical Doctor, Psychiatry) MFA (Master of Arts in Fine Arts, Creative Writing) Board Certification: National Board of Psychiatry & Neurology Academic Post: Clinical Associate Professor, Department of Psychiatry & Behavioral Sciences, University of Washington

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