Nicole Camacho, MA, MHCA, MFTA, CDPT

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Nicole Camacho, MA, MHCA, MFTA, CDPT 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. APPOINTMENTS: Your appointment is held exclusively for you. It is important that you arrive on time and if for any reason you are unable to attend, please call Rainier Behavioral Health to reschedule. You do, however, have a 15-minute grace period but if you believe you will be any later than that, please let us know as soon as you possibly can. Please reschedule within 24 hours of your scheduled appointment. Otherwise, you will be charged a $75 fee for missing your appointment. Rainier Behavioral Health does not give reminder calls for appointments. Therefore, it is your responsibility to remember to attend your appointments, as you will be responsible for the charge. CREDENTIALS: I have associate licenses in Marriage and Family Therapy and Mental Health Counseling in the State of Washington. I also recently completed 2,000 hours in chemical dependency counseling - all client contact. I earned a Master of Arts degree in Marriage and Family Therapy from Chapman University and completed my practicum at the Army Substance Abuse Program on Fort Lewis. I work to uphold the highest ethical standards of care and am also committed to any culturally-sensitive awareness and understanding. PROCESS OF THERAPY: I view psychotherapy as a powerful process of behavioral change. I also view psychotherapy as a chance for individuals to explore a deeper understanding of themselves while working to achieve a complete and healthy life. In our time together, I hope to develop a trusting therapeutic relationship from which we can identify strengths, support, and effective measures to be taken toward living a more meaningful life. With the use of Cognitive-Behavioral Therapy (CBT), psychoeducation, and Dialectical Behavioral Therapy (DBT), we will examine how to overcome internal and external obstacles to reach our goals by understanding the past, but working toward changing the future. 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 Nicole Camacho’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.

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