Graham Cooper, Ph.D.

Please correct the errors described below.

Graham Cooper, Ph.D. Welcome to my office at Rainier Behavioral Health. The following information is provided to familiarize you with my practice and background. CREDENTIALS: I am a licensed Clinical Psychologist with over 7 years of experience providing psychotherapy to a diverse range of clients. I obtained my doctoral training at the Ohio State University before moving to California where I completed a predoctoral internship with the VA Northern California. Following my internship, my family and I moved to Washington for my post doctoral residency at the VA Puget Sound in the Cognitive and Behavioral treatment of PTSD and trauma related disorders. 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. If you are unable to keep your appointment for any reason, please contact the office at least 24 hours in advance to cancel or reschedule; otherwise, you will be charged $75 for the missed session. Insurance will not pay for missed sessions; you will be responsible for the charge. If a pattern of no shows/ late cancellations occurs, our working relationship will terminate, and you will need to obtain care elsewhere. It is your responsibility to remember and keep track of your appointments. Parents of minor children must remain on the premises during the child’s appointment. PROCESS OF THERAPY: I view psychotherapy as a highly collaborative relationship. Making the decision to begin therapy often takes a great deal of courage, which is why I think it is so important to work together on the development of a unique and individualized treatment plan that you can feel confident in. You are ultimately the expert on your own life and experiences, and I strive to help every client I work with see themselves as an equal partner in their treatment and recovery. There are no guarantees that the results of any evaluation or therapy will conform to your every expectation. Effective therapy can sometimes be confusing and emotionally painful. Effective treatment and accurate assessment depend to a significant degree on your openness, your commitment to change, and your collaboration. EMERGENCY CALLS: An answering machine takes all emergency calls outside of regular business hours. If it is a true emergency (self- harm or harm to others) I would suggest calling 911 or the pierce county crisis line at (253) 253.254.7613. BILLING AND PAYMENT: Patients, or their responsible legal guardians, are responsible for their accounts and are expected to pay their bill when due, whether medical insurance pays for a portion or not, including charges for evaluation, printed materials, reports, letters, consultations and telephone calls. When 90 days have passed without a payment, accounts may be sent to collections and the patient or legal guardian may be responsible for any additional legal and/or collection agency charges. Results of evaluations or reports may not be released until accounts are paid in full. I understand that this is an expensive treatment and I am prepared to arrange an extended payment plan. This entails a written agreement to pay a fixed amount regularly each month until the balance is paid. If regular payments stop, the balance will be considered delinquent, and finance charges and collection procedures may be instituted. Bills are sent out monthly and detail the dates of visits, the type of service provided, whether your insurance company had been billed for that visit, and all payments made into your account. If you have any questions about your bill please contact our billing department. You are expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage. If you have insurance coverage you are expected to pay your co-pay at the time of each appointment. If you are uncertain about your co-pay I encourage you to contact your insurer. If you have any other questions on this matter I would suggest asking our office staff. 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. My billing department will submit claims to insurance companies that I am contracted with. 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 notify you of relevant changes. INFORMED CONSENT: your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. INFORMED CONSENT FOR ADULTS: I hereby authorize Graham Cooper, Ph.D. a licensed psychologist, to render psychological services. This authorization constitutes informed consent without exception. I have read and understand the office policy statement and notice of privacy practices and have received a copy of this office policy for myself. INFORMED CONSENT FOR MINORS: Washington State Law recognizes the right of 13- 17 year-old to consent to their own treatment, which also protects their rights to confidentiality. When working with adolescents I believe that it is important to work with the family while preserving the adolescent’s right to confidentiality. Treatment is typically impeded if an adolescent does not feel that he/she has a private place to talk about concerns. Thus I typically seek the adolescent’s consent before speaking with parents. I hereby authorize Graham Cooper, Ph.D. a licensed psychologist, to render psychological services. This authorization constitutes informed consent without exception. I have read and understand the office policy statement and notice of privacy practices and have received a copy of this office policy for myself.

* 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. ** My electronic signature acknowledges that I have read and agree to the terms in the before mentioned office policy. ***

Please note: Rainier Behavioral Health does not provide disability evaluations or court related evaluations.

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