Liz Cotton, LMFT

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Liz Cotton, LMFT Washington State law requires that I share the following information with you and that you indicate you have been informed by signing a copy of this form. Please read the following information carefully. I welcome any questions or concerns you may have regarding this agreement of my services. Credentials: I received a Bachelor of Science in Psychology at Santa Clara University in 1990, a Certificate in Expressive Arts from John F. Kennedy University in 1996 and a Master of Arts in Counseling (Marriage, Family, & Child Counseling) from Sonoma State University in 1998. I worked with youth and families in social services and crisis residential from 1990 – 1996. I have been working as a therapist since 1996 and have worked in a variety of settings. I was licensed by the State of Washington as a Marriage and Family Therapist (No. LF00001495) in 2001. Current Practice: I work with individual adults and adolescents. The issues, symptoms and backgrounds I have worked with is extensive and as a result I would call myself a generalist. I draw largely from a family systems perspective as well as a wide range of trainings – Internal Family Systems, DBT, Trauma Focused CBT, Mindfulness, Play Therapy. I also often incorporate Expressive Art Therapy – visual art, imagery and movement in my work. I provide a space for people to be with all aspects of who they are – mentally, emotionally, physically, and spiritually. I believe we are all experts on our own lives and have within us the knowing of what is best for us. There are times when we feel disconnected from that knowing and can benefit from support in reconnecting with it. I offer space to enter into a deeper exploration of one’s life. I provide support to enter into one’s inner process in order to be with all of the parts of one’s personality and all the information and wisdom held there. I assist others in connecting with a feeling of more internal space and a greater sense of ease from which to reflect on what they are needing. I believe therapy is a collaborative process and feel grateful to have the privilege to join others in their personal process. If, at any time, you feel that your needs are not being met, please let me know so that we can address your concerns. Purpose of Intake: The intake time is both an opportunity to determine if we as client and therapist are a good match and if so, also a chance to gather information about what has brought you in along with some background. Evaluations: At times, therapists are requested to provide evaluations for legal, disability determinations, fitness for duty and other purposes. I prefer to inform clients before beginning therapy that I do not provide letters or reports, nor perform evaluations or assessments for legal or other purposes. If you seek this type of service from your mental health provider, you would be better served by another provider. 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. Confidentiality: Information discussed in therapy is confidential. I will not release any information without your written permission, apart from what is required by law: I may be authorized or required to disclose information you provide to me if I suspect there has been child or elder neglect and/or abuse or if you are a threat of harm to yourself or others, if you are an insurance claim, or if ordered by the court, information regarding your dates of service, diagnosis and treatment plans may be released to your insurance company. Your name and identifying characteristics will not be disclosed if at any time I consult with professional colleagues about general aspects of your case. Appointments: Making and keeping appointments is important to the therapeutic process. Your appointment is held exclusively for you. Please arrive on time as your appointment cannot be extended beyond the scheduled time. If you miss your appointment without proper cancellation (24 hours or more), you will be charged for the time. Insurance does not reimburse for missed sessions and you will be responsible for a fee of $75.00. Illness and Rescheduling: My physician has informed me that I am particularly sensitive to colds and flu. As a result, I ask that if you or your child are sick with a cold or flu that you re-schedule your appointment. If you are in urgent need, we can talk by phone. 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, reception staff would also be able to inform you of any office closings. Emergency Calls: Please do not leave emergency messages on my personal voicemail, as I cannot assure I will retrieve messages after hours or on weekends. When you call Rainier Behavioral Health’s main number (253-475-6021) an answering service takes all emergency calls outside of regular business hours. They will attempt to locate me in the event of an emergency or will contact the on-call clinician if I am not available. *If it is a true emergency (self-harm or harm to others) I would suggest calling 911, going to the nearest emergency room or calling the Pierce County Crisis Line at 1(800)576-7764. Billing and Payment: Patients, or their responsible legal guardians, are responsible for payment of their accounts. I request that you keep current with your portion of the bill (the part not covered by insurance) 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. Ultimately you are responsible for your account and are expected 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 has incurred. If 90 days pass without a payment, accounts may be sent for collection. If you have any questions about your account, you may speak to me or someone in the billing office at any time. Insurance: Be sure to check with your insurance company and our intake office to learn whether I am a provider for your plan. Inquire if your plan requires a preauthorization or a PCP referral, if you have a separate annual deductible for your mental health and whether your mental health benefit has a maximum yearly number of sessions or a maximum yearly amount. Our intake department can assist you with any of these questions. The billing department will submit claims to insurance companies with which I am contracted. In order to for this to occur, you need to provide a copy of your insurance card. Changes to Office Policy: From time to time, the business policies described in this document may be changed. I will attempt to inform you of the relevant changes. Consent for Treatment: I have read Liz Cotton’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 in many cases 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 or guardians about matters discussed in therapy. With this said, the same limits to confidentiality that apply to adults (explained on the first page) also apply to minors. If a minor (13-17) is seeking treatment, please sign below regarding consent to treatment as described in this 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.

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

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