• Patient Intake Information

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  • Disclosures and Acknowledgements

    Privacy Practices, Disclosures, and Consent
  • PLEASE READ CAREFULLY: By signing below, I agree to begin therapy with Counseling West Seattle for the disclosed fee, and to pay deductible and/or co-pay portions at the beginning of each session. I understand that if insurance does not cover the entire amount, I am responsible for the full cost of my treatment.

    CANCELLATIONS: If I am unable to keep a scheduled appointment for any reason, I must notify my provider at least 24 hours in advance or I will be charged the full amount for the allotted time.

  • Document: Privacy Practices (Click to View)

  • Disclosure Statement: Alexa Harmon, M. Ed, NCC, CCM, LMHC

    Disclosure Statement: AnnaMaria Austin, M. Ed Psy, LMHCA

    Disclosure Statement: Aubrey Hardesty, Psy.D., LMHCA

    Disclosure Statement: Colette Swenson, M. Ed., LMHCA

    Disclosure Statement: Elliot Grossman, MSW, LICSW

    Disclosure Statement: Eric Mulholland, MA, LMHCA

    Disclosure Statement: Ernie McGarry, MC, LMHC

    Disclosure Statement: Gayle Zeller, MA, LMHC

    Disclosure Statement: Katherine Lincicum, MSW, MPH, LICSW

    Disclosure Statement: Larisa Wendfeldt, MA, LMFT

    Disclosure Statement: Toni Napoli, MA, LMHC

  • Signatures

  • Document: Telebehavioral Health Informed Consent (Click to View)

  • Please fill out the following information about your child:
    *      *   *   and agree to the terms on his/her behalf.
          

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  • For Office Use Only

    Counselor Acknowledgement and Signature
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