Practice Disclosures, Policies, and Procedures

Emily Sinclair Counseling, PLLC - this form will take 10-15 minutes to read and sign

Please correct the errors described below.

CONTENTS:

  • My Practice Disclosure Statement
  • Payment and Cancellation Policies / Current Fee Schedule
  • Confidentiality Rights and Responsibilities
  • Client Rights Regarding HIPAA Authorizations
  • Agreements, Signature, Date

My Practice Disclosure Statement

Welcome to my practice.

I am honored to have you as a client. This document will inform you about me, my professional services and my business policies. Please pay careful attention and jot down any questions you might have so that we can discuss them during our first session. When you sign this document, it will become a mutual agreement between us.

Education and Licensure

I have a Masters of Psychology – Systems Counseling, from LIOS Graduate College of Saybrook University. This program is accredited, well-rounded, integrated, and experiential, and I have an excellent foundation to have a productive and successful career as a psychotherapist. I am a Licensed by the State of Washington as a Mental Health Counselor (LMHC), license number: LH 60528134. Though I am fully licensed, ongoing supervision and consult group participation will be important throughout my career. I will pursue continuing education and advanced training in many realms of treatment.

The Therapy Process

Psychotherapy is a process of examining feelings, thoughts, behaviors, and relationships that cause distress. The goal of psychotherapy is to help an individual, couple, or family, examine and change distressing areas in life, and to reduce suffering. Your active participation is a necessary part of this process. By signing this contract, you are committing to prioritize your appointments with me. To maximize the benefit of therapy in your quest to heal and change, you must commit and be consistent. While I cannot guarantee that any specific goal will be achieved, your ability to be open and honest with me will greatly enhance the effectiveness of your therapy.

I am dedicated to working through the entire therapeutic process with you. I have a general practice, which means that I work with a variety of problems facing adults and families. The process of psychotherapy varies depending on the personalities of the therapist and the client, and the particular problems you bring forward. Since I have an eclectic and integrated education, there are many different methods I may use to address the problems you bring to therapy, ranging from the pragmatic to the more symbolic and expressive. Some problems result in physical conditions and medical consultation may be advised. I believe body, mind and soul are connected, and when one part of you suffers, all areas in your life are affected. Your health and happiness are important to me.

What to Expect

I normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need. If I determine that your problems are not within the scope of my expertise, I will provide you with a referral to a more appropriately specialized therapist.
If we work together, we will try to determine a regular meeting time for your sessions. I usually schedule a 50-minute session every week, although some sessions may be longer or more or less frequent depending on your situation. You can expect therapy to last anywhere from a few weeks to a few years depending on the nature of your concerns and the amount of change you want to make in your life. Typically, the end of therapy occurs when the problems for which you sought help have been alleviated.

Rights, Responsibilities, and Records

Therapy is a relationship that works in part because of clearly defined rights and responsibilities held by each person. This frame helps to create the safety to take risks and the support to become empowered to change. As a client in psychotherapy, you have certain rights that are important for you to know about because this is your therapy, and my goal is your well-being. There are also certain limitations to those rights that you should be aware of. As your therapist, I have corresponding responsibilities to you.

  • If at any point you have questions or concerns about our relationship or the direction of our work together, please feel free to address these with me. You also have the right to a second opinion, a different approach, or a different therapist.
  • I keep a record of the services I provide you. You may ask to see and copy that record. You may also ask me to correct that record. I will not disclose your record to others unless you direct me to do so or unless the law authorizes or compels me to do so. You may see your record or get more information about it by asking me. You may also request that I NOT keep notes for your file, by signing a legal authorization form.
  • You are free to leave therapy at any time. You have the right to refuse anything that I suggest. You are also free to discuss your treatment with anyone you wish, and you do not have any responsibility to maintain confidentiality about your therapeutic experience since you are the person who has the right to decide what you want kept confidential.
  • Therapists do not have social or sexual relationships with clients or former clients because that would not only be unethical and illegal, it would be an abuse of the therapist’s power.
  • Therapy has potential emotional risks. Approaching feelings or thoughts that you have tried not to think about for a long time may be painful. You may feel worse before you feel better. Making changes in your beliefs or behaviors can be scary and sometimes disruptive to the relationships you already have. You may find your relationship with your therapist to be a source of strong feelings. It is important that you consider carefully whether these risks are worth the benefits to you of changing. Most people who take these risks find that therapy is helpful.
  • Therapy may also be ended under the following conditions: If I determine that I am not able to help you because of the kind of problem you have or because my training and skills are not appropriate, you will be informed of this fact and referred to another therapist who may better meet your needs. In addition, if you cancel three appointments in a row, or frequently cancel appointments, we will evaluate whether we are a good fit, and I reserve the right to end therapy and refer you to another therapist.
  • If you do violence to, verbally or physically threaten or harass me, my office colleagues, or my office, or ask me to engage in any illegal conduct, you will be unilaterally and immediately terminated from treatment. Under this circumstance, a report will be filed with the police, and no referrals will be provided.

Complaints / Unprofessional Conduct

Washington State law requires that I inform you that if you have a concern or complaint about a licensed therapist, or if want to confirm that a particular therapist is licensed, you may contact the Department of Health at the following address, phone number or email: Health Professions Quality Assurance, Customer Service Center, P.O. Box 47865, Olympia, WA 98504-7869, 360.236.4700, hpqa.csc@doh.wa.gov. If you are unhappy with what's happening in therapy, I hope you'll talk about it with me so that I can respond directly to your concerns. I will treat such feedback seriously and with the utmost care and respect.

Professional Supervision and Consultation

I participate in ongoing consultation with other mental health professionals, and in ongoing continuing education and supervision. Such activities allow me to stay current with professional standards and new developments in the field. It also allows me to receive valuable input on my work. When discussing cases, I will not disclose any identifying information about you.

Messages and Emergencies

Phone Calls, Texts, Messages: You may leave a confidential message on my voicemail at any time. I regularly check for messages. Unless I am on vacation, I will make every effort to respond within 24 business hours of the time you try to reach me. I may respond with a text or brief message if we have a pending appointment, and prefer to discuss matters in person if possible.

Emergencies: As an individual therapist in private practice, I am unable to respond immediately to your calls or texts in an emergency. Therefore, if you are experiencing a crisis or emergency, please call the Crisis Clinic: 206-461-3222. If you believe that you cannot keep yourself safe, please call 911, or go to the nearest hospital emergency room for assistance. Please call me after you have taken care of getting immediate help in a crisis.

Payment and Cancellation Policies / Current Fee Schedule

Fees and Payment

Payment in full is due at each session. I will evaluate my fee periodically, which is subject to change based on additional training and expertise, or other factors. Rates listed are for cash/check pricing. If you are paying by check, please make it payable to: Emily Sinclair Counseling. A $25.00 fee will be assessed for returned checks. Any outstanding balances will be sent to a collection agency.

I also accept debit and credit cards in my office through IvyPay - an encrypted app which will store your credit, debit or HSA card safely online. When paying with credit and debit cards, there will be a small handling fee added to your total. By signing this document you are verifying knowledge of this handling fee.

Scheduling and Unpaid Sessions

Please handle any administrative details such as future cancellations or rescheduling at the beginning of a session. Future appointments will not be scheduled if sessions remain unpaid. This policy is designed to prevent you from incurring a large bill that may be difficult to pay at a later time.

Fee Schedule as of May 2018

Individual, Couples, Families, Multi-body Session Rates (for Cash/Check):
$150 – 45-50 minute session (i.e. 1:30 – 2:20pm)
$225 – 70-75 minute session (1.5 sessions, i.e. 1:30 to 2:40 or 2:45pm)
$300 – 90-100 minute session (2 sessions, i.e. 1:30 to 3:00 or 3:10pm)
$375 – 120 minute session (2.5 sessions, i.e. 1:30 to 3:30pm)
$450 – 150 minute session (3 sessions, i.e. 1:30 to 4:00pm)
$1200 – All day session (7 therapy hours, with a mid-point hour break)

Insurance

Most health insurance plans cover some therapy services, and will reimburse for an “out of network provider.” I encourage you to check your plan carefully to determine what is covered under your plan. I am not on any insurance panels. I am happy to provide you with a "super bill" to submit to insurance for reimbursement. I also currently submit insurance claims online, for a few clients who have special circumstances or difficulty submitting super bills, about every two months or so.

You should be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. I may also have to provide additional clinical information such as treatment plans or summaries or in rare cases a copy of the entire record. This information will become part of the insurance company file. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it. Upon request, I will provide you with a copy of any report I submit.

Please note: Some insurance companies require pre-authorization and specific diagnoses to approve sessions longer than 45-50 minutes. In addition, many insurance companies do not reimburse for Couples Therapy, or for Telehealth (telephone or video) therapy - though this is changing. Please verify this if you are concerned about reimbursement.

Other Services and Legal Involvement

In addition to weekly appointments, I charge the same rates for other professional services you may need (with the exception of legal involvement – see below). I will pro-rate the hourly cost if I work for periods less than one hour. Other services include report writing, telephone conversations lasting longer than 5 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and time spent performing any other service you request of me.

If you are, or become, involved in legal proceedings that require my participation, you will be expected to pay for my professional time - and any legal counsel needed to support my work and protect my professional status and license - even if I am called to testify for another party. Because of the difficulty of legal involvement, I charge $300 per hour for research, preparation and attendance at any legal proceeding. I will not bill insurance companies; however, I will be happy to provide you with a receipt of service that you may submit for reimbursement. You will have to research your individual policy to see what it covers.

Phone Calls and Texts

Phone calls lasting longer than five minutes will be billed at my regular hourly rate. Generally, I do not conduct telephone or video therapy sessions, unless special circumstances exist. Exceptions to this policy are made at my discretion.

Cancellations and Missed Appointments

If you are unable to keep an appointment for any reason, please text or leave a message on my voicemail AT LEAST 48 HOURS in advance of your appointment. The full fee is collected for missed or cancelled appointments with less than 48 HOURS notice. If you are a no-show and do not contact me, you automatically forfeit future appointment times. Lack of response to an automated courtesy text reminder is NOT a cancellation. If you miss or cancel three sessions in a row, or frequently cancel appointments, we will discuss whether we are a good fit, and I reserve the right to end therapy and refer you to another therapist. And finally, if you are late for your session for any reason, the full fee will still be charged. Please note: insurance companies do not reimburse for cancelled or missed sessions.

Confidentiality Rights and Limitations

Confidentiality

What you say to me in psychotherapy is strictly confidential. I will not release any information about you or about what has gone on in your therapy without your written permission. You may direct me in writing to share information with whomever you chose, and you can change your mind and revoke that permission at any time, and no further information will be released. I will always act so as to protect your privacy even if you do release me in writing to share information about you. You may request anyone you wish to attend a therapy session with you; if you wish to do so, please discuss this with me.

Limits of Confidentiality

Washington State law requires release of information without a client’s consent in certain circumstances. The following are legal exceptions to your right to confidentiality. You would be informed at any time when these exceptions are put into effect.

  • Health Care Information Act of 1992 -- Under the provisions of the Health Care Information Act of 1992, a therapist may legally speak to another health care provider or a member of your family about you without your prior consent. However, I will not do so unless the situation is an emergency.
  • Duty to Warn and Protect -- When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client. If your therapist believes that you are in imminent danger of harming yourself, she may legally break confidentiality and call the police or the county crisis team.
  • Abuse of Children and Vulnerable Adults -- If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate Child Protective Services and Adult Protective Services and/or legal authorities within 48 hours.
  • Prenatal Exposure to Controlled Substances -- Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.
  • Minors/Guardianship -- Parents or legal guardians of non-emancipated minor clients (under age 13) have the right to access the clients’ records.
  • Insurance Providers (when applicable) -- Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes, but is not limited to: types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries.
  • Sexual Misconduct of a Licensed Therapist -- If you reveal information about the impairment or sexual misconduct of another psychotherapist licensed in the State of Washington, your therapist is required by law to report that conduct to the Dept. of Health.
  • Legal Subpoena -- In response to a subpoena, your therapist may be required to submit her notes or information regarding your case, in which case your therapist will do everything in her power to protect you as a client, will remain your advocate, and will be advised by an attorney as to the minimum response required.

Confidentiality Issues for Couples

When working with a couple I treat the couple as my client. With respect to confidentiality this means that I do not keep secrets. Anything that is told to me by an individual will be shared with the other member of the couple. Such open communication is crucial to effective couples therapy. In addition, I will not testify for or against either individual in a court proceeding. Again, my reason for this policy is my responsibility to both individuals as a couple rather than as separate units.

Electronic Communication

You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law insures the confidentiality of all electronic transmission of information about you. If you elect to communicate with me by email and text at some point in your work together, please be aware that email and text communication is not completely confidential. All emails are retained in the logs of the internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email received from you, and any responses sent to you, will be saved for your treatment record. Please see the following complete HIPAA form for more information about client rights.

Client Rights Regarding HIPAA Authorizations

The following specifies your rights under the Health Insurance Portability and Accountability Act of 1996, as amended from time to time (“HIPAA”).

1. Tell your mental health professional if you don’t understand an authorization to release your private medical information, and they will explain it to you.

2. You have the right to revoke or cancel a release authorization at any time, except: (a) to the extent information has already been shared based on an authorization; or (b) this authorization was obtained as a condition of obtaining insurance coverage. To revoke or cancel an authorization, you must submit your request in writing to your mental health professional and your insurance company, if applicable.

3. You may refuse to sign an authorization. Your refusal to sign will not affect your ability to obtain treatment, make payment, or affect your eligibility for benefits. If you refuse to sign an authorization, and you are in a research-related treatment program, or have authorized your provider to disclose information about you to a third party, your provider has the right to decide not to treat you or accept you as a client in their practice.

4. Once the information about you leaves this office according to the terms of an information release authorization, this office has no control over how it will be used by the recipient. You need to be aware that at that point your information may no longer be protected by HIPAA.

5. If this office initiated an authorization, you must receive a copy of the signed authorization.

6. Special Instructions for completing an authorization for the use and disclosure of Psychotherapy Notes. HIPAA provides special protections to certain medical records known as “Psychotherapy Notes.” All Psychotherapy Notes recorded on any medium (i.e., paper, electronic) by a mental health professional (such as a psychologist or psychiatrist) must be kept by the author and filed separate from the rest of the client’s medical records to maintain a higher standard of protection. “Psychotherapy Notes” are defined under HIPAA as notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separate from the rest of the individual’s medical records. Excluded from the “Psychotherapy Notes” definition are the following: (a) medication prescription and monitoring, (b) counseling session start and stop times, (c) the modalities and frequencies of treatment furnished, (d) the results of clinical tests, and (e) any summary of: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

In order for a medical provider to release “Psychotherapy Notes” to a third party, the client who is the subject of the Psychotherapy Notes must sign an authorization to specifically allow for the release of Psychotherapy Notes. Such authorization must be separate from an authorization to release other medical records.

Agreements, Signature, Date

Master Agreement

Thank you for your consideration and integrity regarding these important policies and contractual obligations.

Checking the following boxes and an electronic signature below serves as a Master Agreement to all policies of Emily Sinclair Counseling, PLLC, and verifies that I understand and agree to all policies in the sections listed here:

format: 1/11/2020

Insurance Submittal and Super Bill Authorization

If you plan to request insurance reimbursement, you must check the box agreeing to the following release of information.

Your information will be encrypted.

Loading...