Susan J. Poole, Ph.D.

Please correct the errors described below.

Susan Poole, Ph. D.
APPOINTMENTS: Your appointment time is held exclusively for you. Therapy appointments last for 45 minutes. 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 the $75 for the missed session. This office does not give reminder calls for appointments. It is your responsibility to remember and keep track of your appointments. As insurance will not pay for missed sessions, you will be responsible for the charge.

CREDENTIALS: I am a psychologist licensed in the State of Washington. I earned a doctoral degree (Ph.D.) in psychology from Washington State University in 1998 and completed an internship at Duke University in counseling psychology. As a member of the American Psychological Association and as a psychologist licensed by the State of Washington, I work to uphold the highest ethical standards.

PROCESS OF THERAPY: I view psychotherapy as a powerful process with the potential to change unhealthy life patterns, reduce uncomfortable emotional symptoms, restore a feeling of control over life and improve self-esteem. To accomplish your goals, you and I will need to form a partnership: I will do my best to provide effective treatment, and you will need to make personal commitment to try new things. You will assume a good deal of responsibility –and credit- for our ultimate success. Unlike medicine, in which you simply describe your symptoms and the doctor cures your illness, psychotherapy challenges you to begin actively changing the way you think about and respond to life. I practice an eclectic therapeutic orientation and will endeavor to explain to you the kinds of treatments that are typically used, approaches to assessment, and length and course of treatment for the issues you present.

There are no guarantees that the results of any evaluation or therapy will conform to your every expectation. I make no promises to determine any particular diagnosis or to reach any particular conclusion for an evaluation. In fact, effective psychotherapy is sometimes confusing, and it is sometimes 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 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 psychologist if I am not available. After hours calls are typically charged a fee based on a prorated amount for the length of the call. You may also call the crisis line at: 253-798-4333 (Pierce County) or 206-461-3222 (King County).

FEES: My fees are $270 for the initial appointment. Fees for testing, reports, letters, review of records, and phone calls will be based on the amount of time required, at a rate of $215 per hour.

BILLING AND PAYMENTS: Patients, or their responsible legal guardian, 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. A finance charge of 1% per month may be added to any balance not paid within 60 days after the charge was incurred. When 90 days have passed without a payment or prior arrangement with me, accounts may be sent for collection and the patient or legal guardian may be responsible for any additional legal and/or collection agency charges. Results of evaluation 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 ask me or 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. The co-pay for mental health is often different from that for other medical visits. If you are uncertain about your co-pay I encourage you to contact your insurer. Until you know for certain what your co-pay is, I would ask that you pay 20% of my fee (e.g., $30) at the time of each appointment.

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 Susan J. Poole, 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-olds 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 s/he has a private place to talk about concerns. Thus, I typically seek the adolescent’s consent before speaking with parents. Of course, the same limits to confidentiality that apply to adults (listed in the following section) also apply to minors.

I hereby authorize Susan J. Poole, 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.

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

Authorized Representative or Guardian Signature (if applicable)

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