Catherine A. J. Mulhall, MSW

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Catherine Mulhall, MSW Washington State law requires that I share the following information with you and that you indicate you have been informed by signing one copy of this form. Please read the following information carefully. I welcome the opportunity to discuss any questions or concerns you may have regarding this agreement or my services. EDUCATION: I hold a Bachelor of Arts degree in Social Work and Psychology from Pacific Lutheran University and a Master of Social Work degree from the Catholic University of America. I have worked in outpatient mental health since 2001. I am a member of the National Association of Social Workers (NASW) and am licensed by the State of Washington as a licensed independent clinical social worker (LW00007980). I ascribe and adhere to the Code of Ethics of the NASW and to the ethical and professional standards of the Washington State certification law. APPROACH TO THERAPY: I use a multi-model approach to psychotherapy, applying the models of treatment most appropriate to each client’s individual needs. In addition, I use a “strength-based” philosophy, helping clients identify, utilize, and further develop their own strengths. Therapy is a process in which the client and therapist can work together to address issues and obstacles to a happy, healthy and fulfilling life. The therapeutic process is a period of personal growth that we will navigate together. If, at any time, you feel that your needs are not being met, please let me know so that we can address your concerns. Thank you for the opportunity to work together. Legal Evaluation: At times, therapists are requested to provide evaluations for legal purposes. I prefer to inform clients before beginning therapy that I do not provide letters or reports, nor perform evaluations or assessments for legal purposes and do not do legal work. In addition, I do not find it productive therapeutically to communicate verbally or in written form with attorneys and do not act in this manner as a therapist. If you seek this type of service from your mental health provider, you would be better served by another provider. Please let me know the nature of what you seek before we begin. If you require legal work of any kind, I will refer you back to your referral source prior to assessment. Disability Evaluation: I do not provide letters, reports, or assessment for disability or fitness for duty (work) purposes. If you are seeking a disability evaluation upon entering our clinic, it is important for you to share this goal up front. If you have this need, please inform me or our triage staff prior to our first meeting in order to determine whether you need an alternate referral. APPOINTMENTS: Your appointment time is held exclusively for you. It is important that you arrive on time for your appointment, as it cannot be extended beyond the scheduled time. If you are unable to keep your appointment for any reason, you must give at least 24 hours or one full business day advanced notice to cancel or reschedule; otherwise you will be charged $75 for the time reserved for you. (Monday appointments need notification before your appointment time on the preceding Friday.) Please be aware that most insurance companies will not reimburse for missed/late canceled sessions, making you responsible for the entire fee. This office does not give reminder calls for appointments. It is your responsibility to remember and keep track of your appointments. WEATHER: On the occasion of severe weather when you have a scheduled appointment, please phone my office to inform them whether or not you will be able to keep your appointment. At this time, the reception staff would also be able to inform you of any office closings. EMERGENCY CALLS: An answering service takes all emergency calls outside of regular business hours. This service will attempt to locate 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 portion of the fee payment prior to each session. If you are unable to manage this, please work out a payment arrangement with the billing office in advance so that you are able to keep your account up to date each month. If your session occurs when the billing staff is unavailable, it is your responsibility to contact them at your earliest convenience regarding your bill. Ultimately, you are responsible for your account and are required to pay your bill, whether insurance pays for a portion or not. A finance charge of 1% per month may be added to any balance not paid within 60 days after the charge is incurred. If 90 days pass without a payment, accounts may be sent for collection. If you have any questions about your account, please ask my bookkeeper. INSURANCE: I am a contracted provider for many, but not all, local insurance companies. You should be sure to check with your insurer and my intake office 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 benefit, 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. Even if the staff in my office is checking into benefits and authorization on your behalf, it is important for you to verify this information as well to ensure your authorization and ongoing coverage. In addition, you will need to keep our staff up to date with any changes to benefits or your policy, as the billing staff will not be automatically notified of these changes which may affect your coverage. Once you decide to utilize my services, the billing department will submit claims on your behalf to insurance companies with which I am contracted. In order for this to occur you must complete the insurance portion of the “Patient Information” form that was given to you with this office policy; you also need to provide a copy of your insurance card. CHANGES TO THIS OFFICE POLICY: From time to time I may change the business policies described in this document; I will attempt to inform you of relevant changes. CONSENT FOR TREATMENT: I have read Catherine Mulhall’s Office Policy Statement and understand it. I consent to therapy under the terms described above and understand that I have the right to terminate treatment at any time. My signature below indicates I have received a copy of this agreement.

* 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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