Amy Dwyer, MSW, LICSW

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Amy Dwyer, MSW, LICSW The following information represents informed consent related to my professional services and business policies. Washington State requires that I provide you with this information; your signature represents an agreement between us. Please read all of the information carefully. I welcome the opportunity to answer any questions or concerns you may have regarding this agreement or my services. CREDENTIALS: I hold a Bachelor’s of Science Degree in Psychology from Oregon State University (1997) and a Master’s of Social Work Degree from Portland State University (2002). I have worked in outpatient and inpatient mental health settings since 2002. My professional experience includes individual, family, and group therapy in the treatment of children, adolescents, and adults. I have been trained in several evidence-based practices, including Cognitive-Behavioral Therapy for Depression and Anxiety, Trauma Focused Cognitive-Behavioral Therapy, Aggression Replacement Therapy, and Dialectic Behavior Therapy. I am licensed by the State of Washington as a Licensed Independent Clinical Social Worker (#00009495). I ascribe and adhere to the National Association of Social Worker’s Code of Ethics as well as to the ethical and professional standards of the Washington State certification law. GENERAL APPROACH TO PRACTICE: I believe in a collaborative approach to therapy. In partnership, we will work to explore your needs and develop a treatment plan to address identified issues. I primarily employ a cognitive-behavioral approach as this treatment modality has been shown to be effective in therapy. In addition, I use a strengths-based framework. Together we will address symptom management, build on your pre-existing strengths, and further develop your coping strategies. In addition, our work will likely include making meaning of important life events. Treatment work with children, adolescents and families also routinely includes exploring developmental issues and providing strategies for caregivers. Please be aware that I do not perform evaluations or assessments for legal purposes, social security disability, or psychological reports. APPOINTMENTS: Your appointment time is held exclusively for you. It is important to arrive on time as your appointment cannot be extended. If you are unable to attend your appointment for any reason, please contact the office at least 24 hours in advance in order to cancel or reschedule, otherwise you will be charged $75.00 for the missed session. The office does not provide reminder calls and it is your responsibility to remember and keep track of your appointments. As insurance does not pay for missed appointments, you will be responsible for the charge. Parents of minor children must remain on the premises during the child’s appointment. EMERGENCY CALLS: An answering service takes all emergency calls outside of business hours through Rainier Behavioral Health main number (253-475-6021). This service will attempt to contact me in the event of an emergency and will contact the on-call clinician if I am not available. BILLING AND PAYMENTS: Please remember that fee payment is your responsibility. I request that you keep current with your insurance co-payments prior to each session. A finance change of 1% of your unpaid balance may be charged to your account after 60 days of incurred charges. If 90 days passes without payment, accounts may be sent to collection. INSURANCE: I am contracted with many, but not all, local insurance companies. Please be sure to check with your insurance company and our office intake staff to learn whether I am a provider for your plan. You should also learn whether you need a referral or preauthorization in order to be eligible for your mental health benefits, whether you have a separate annual deductible for mental health, and whether your mental health benefit has a maximum yearly number of visits or a maximum yearly dollar amount. It is your responsibility to be aware of your mental health benefits and to keep our billing department updated on any changes to your benefits or coverage. Our billing department will not be automatically notified by your insurance provider of changes that may affect your coverage. Our billing department will submit claims on your behalf to your insurance provider. In order for this process to occur, you will need to complete the insurance portion of the ‘Patient Information’ form provided with this office policy. CHANGES TO OFFICE POLICY: From time to time I may change the business policies outlined in this document; I will attempt to inform you of relevant changes. CONSENT FOR TREATMENT: I have read Amy Dwyer’s Office Policy Statement and understand it. I consent to therapy under the terms described above. I understand that I have the right to terminate treatment at any time. My signature below indicates that I have received a copy of this statement. CONSENT FOR TREATMENT OF MINORS: Washington State Law recognizes the right of 13 to 17-year-olds to consent to their own treatment which also protects their right to confidentiality. I believe that it is important to work with the family while preserving the adolescent’s right to confidentiality. Treatment efforts are typically impeded if an adolescent does not feel s/he has a protected place to discuss concerns. As such, I typically seek the adolescent’s consent before speaking with parents about matters discussed in therapy. With this said, the same limits to confidentiality that apply to adults (identified in the following section) also apply to minors. If a minor (13-17-years-old) is seeking treatment, please sign below regarding consent to treatment as described in Amy Dwyer’s Office Policy Statement

* I acknowledge I have read the financial policy above and that I am responsible for all charges regardless of any insurance coverage I have. I understand that delinquent accounts may be assigned to a credit reporting collection agency and agree to pay for all legal costs and expenses including reasonable attorney fees. By signing this Acknowledgement, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

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