[For Two Households]
Informed Consent and Practice Policies
I. Introduction
Thank you for choosing Seattle Play Therapy. This document will provide you with important practice information and policies and your rights as a consumer.
Washington state law requires that all counselors providing services for a fee must be registered or licensed with the Washington State Department of Health for the protection of the public health and safety of their clients. Being licensed by the department does not include recognition of any practice standards, nor necessarily implies the effectiveness of any treatment.
For more information about your therapist, see the attached individual Disclosure Statement.
II. Appointments
Appointments are scheduled either in person or online (see Section IV Teletherapy) and are generally scheduled twice weekly, weekly, or every other week for 25 min - 53 minutes. Because your time is saved for you, there is a 48-hour cancellation policy, and a fee will be charged if that is not met. All other financial information, including the costs of all services, can be found in the attached financial agreement.
III. Inclement Weather Policy
Our office does not make practice-wide decisions about snow/inclement weather. We look to the Seattle School District for guidance regarding snow/inclement weather closures, although it’s up to therapists’ discretion to determine their ability to make it into the office safely. If you have an in-person session scheduled, your therapist will check in with you about canceling due to a snow day or switching to telehealth (if clinically applicable) or canceling the appointment.
IV. Holiday & Summer Policy
Seattle Play Therapy operates on a year-round schedule. Regular and consistent attendance is essential to the therapeutic process. If there is a pattern of cancelled appointments (with 48-hours’ notice or not), Seattle Play Therapy may not be able to continue to provide services for your child. In addition, missing or cancelling more than 3 consecutive sessions may result in termination of treatment. In some cases, a leave of absence can be accommodated if arrangements are made in advance with your therapist.
V. Teletherapy, Therapeutic Space and Electronic Tools
If it is clinically appropriate, your therapist will meet with you (or your child/family) via video call, at your own home. This can create challenges as it relates to therapeutic boundaries and to structuring the time/space. We ask that you create similar therapeutic boundaries that you would if you were meeting with your therapist in-person including, but not limited to: signing in on time, being fully clothed, giving your child privacy and a confidential space, etc.
Though engaging in face-to-face counseling often is ideal, virtual therapy can offer an alternative when barriers such as distance, inclement weather, and health and safety issues are present. While teletherapy can be a useful alternative, we are unable to provide teletherapy to clients outside of the state of Washington, even if it is just for a short time. If you are traveling out of state, please inform your therapist and cancel your teletherapy session.
SPT uses HIPAA compliant video conferencing platforms to conduct virtual sessions (for example, Microsoft Teams, Doxy.me, and Zoom). In addition, your therapist may also use third-party applications, videos, games, and other activities to engage with your child online. When engaging in online games it is possible that your child may interact with others online which may compromise their confidentiality. Therapists work to structure and limit these interactions, where necessary, and create therapeutic benefits from them.
There are risks associated with using technology for therapeutic purposes, including but not limited to: web security, confidentiality, and personal privacy (i.e., household members may overhear). Additionally, because we are not physically in the room, we are not able to guarantee you or your child’s safety, though we take reasonable efforts to set limits and redirect your child to a safe option. An adult must be in the home during your child’s entire therapy session and reachable by phone.
Other limitations of using this medium include lack of full body non-verbal cues and poor network connection/dropped calls. Additionally, it’s also possible that you or your child are more easily able to end the call during times of distress. It is strongly encouraged that you continue to work with your therapist through the scheduled hour to work through these challenges.
In some cases, audio-only telehealth must take place due to network connection or other variables. We are required to obtain your consent before we bill you, or your insurance, for audio-only telehealth. Additionally, if you have not been seen in-person by your provider within a year, your insurance may also not cover audio-only telehealth. You may opt-out of audio-only telehealth, and therefore not consent to have us bill you for audio-only telehealth.
VI. Outdoor Therapy
In certain cases, we may request to take therapy outside. We will always speak to you verbally before doing so. When meeting outdoors, your confidentiality may be compromised, including but not limited to: seeing someone you know, others overhearing your conversation, etc.
Additional risks include that you or your child may be exposed to elements that would not otherwise occur in an office-based session, including but not limited to: bug bites, getting dirty, wet, physical injury (such as sprained ankle, muscle strain, etc.) Additionally, without the physical walls of the office, your child might run away or outside of the therapist’s immediate ability to keep your child safe. If you believe this may be a risk, please communicate this to your therapist.
Finally, because you will be meeting with your therapist outside of the traditional therapeutic office space, it is important to define that this is still a therapeutic encounter, not to be misconstrued as any other type of relationship. As such, therapeutic roles and boundaries will still be in place.
VII. Contacting Your Therapist
If you have questions or concerns that cannot wait until your session, you may email us. Please be advised that email may not be a secure form of communication, and that emails with therapeutic content are often copied and pasted into your child’s clinical record. You may also call and leave a confidential voicemail message, and your call will generally be returned within 2 business days.
There will be no additional charge for infrequent communication regarding scheduling or other matters, however, phone calls and emails of excessive length or that discuss information related to treatment will be billed at 15-minute increments at rates listed in the next section.
VIII. Financial Responsibility
Payment is due at the time of service. Services are billed at the amount listed in the table below unless otherwise determined in a Reduced Rate Addendum. For unpaid balances of over $200, we may be required to pause or terminate services. In such cases, we will provide you with appropriate referral resources for low alternatives.
Licensed Professional or Associate Licensed Professional Rates:
- Intake (CPT Code 90791): $250
- Individual Therapy (CPT Code 90837): $200 per 53 min session
- Play Therpay Add-On (CPT Code 90785): $20 per 53 min session
- Caregiver Only Session (CPT Code 90846): Scheduled at 26 min/45 min/55 min - $200/$170/$130
- Family Therapy Session (CPT Code 90847): Scheduled at 26 min/45 min/55 min - $200/$170/$130
Not Billable to Insurance:
- Coordination of Care- (Communication with caregivers, outside providers, including letters, emails, phone calls, school meetings, school observations, written treatment summary etc.) - $50/15-min increments
Missed Session/Canceled <48 hours’ notice - $120
Insurance
SPT will bill your in-network insurance carrier. You are fully responsible for payments of all services rendered and will be charged for any services not covered by the Third Party Payor, or any unpaid or recouped insurance claims after 90 days. Please note that in order to bill insurance, your therapist will need to provide treatment information to your insurer, including a mental health diagnosis.
Superbills (for out-of-network insurance) are provided upon request.
Loss of Insurance Coverage: You are responsible for knowing the limits of your medical coverage and will inform SPT of any changes to your insurance coverage.
Clinical Intern Rates (All services with a clinical intern are not billable to insurance).
- Intake: $130
- Individual Therapy: $90 per 53 min session
- Caregiver Only Session: Scheduled at 26 min/45 min/55 min - $90/80/60
- Family Therapy Session: Scheduled at 26 min/45 min/55 min - $90/80/60
- Coordination of Care- (Communication with caregivers, outside providers, including letters, emails, phone calls, school meetings, school observations, written treatment summary etc.) - $30/15-min increments
- Missed Session/Canceled <48 hours’ notice - $60
SPT will bill your in-network insurance carrier. You are fully responsible for payments of all services rendered and will be charged for any services not covered by the Third Party Payor, or any unpaid or recouped insurance claims after 90 days. Please note that in order to bill insurance, your therapist will need to provide treatment information to your insurer, including a mental health diagnosis.
Superbills (for out-of-network insurance) are provided upon request.
Loss of Insurance Coverage: You are responsible for knowing the limits of your medical coverage and will inform SPT of any changes to your insurance coverage.
For unpaid balances of over $200, we may be required to pause or terminate services. In such cases, we will provide you with appropriate referral resources for low alternatives.
IX. In Case of Emergency
If you are experiencing an emergency, please dial 911, 988, or go to the nearest emergency room. If you are experiencing a crisis and it’s after hours (after 6pm on weekdays, and the weekends) call 988, or the King County 24-hour crisis line at (206) 461-3222, or the National Crisis Line at (800) 273-8255.
X. Minors
In the state of Washington, minors' consent to counseling services begins at the age of 13 years. A child between the ages of 13 and 18 may obtain counseling without parental permission and grants the minor confidentiality. Parents of a minor between the ages 13 and 18 may initiate an assessment and limited treatment for an adolescent without the adolescent’s consent (RCW 71.34.650). Parents of minors under the age of 13 may obtain the records of treatment. To maintain the trusting relationship between therapist and child, it is advised that parents allow the therapist discretion with respect to disclosure of the child’s therapeutic information to the parents. Of course, a threat to safety to self or others is the general exception (see confidentiality).
XI. Confidentiality & Exceptions
Your participation in clinical services, the content of our sessions, and any information we maintain about you is protected by legal confidentiality. Some exceptions to confidentiality include the following situations in which we may choose to, or be required to, disclose this information:
· If you give us written consent to release the information to another party;
· In the case of your death or disability, we may disclose information to your personal representative;
· If you waive confidentiality by bringing legal action against your therapist;
· In response to a valid subpoena from a court or from the Secretary of the Washington State Department of Health for records related to a complaint, report, or investigation;
· If we reasonably believe that disclosing confidential information will avoid or minimize an imminent danger to your health or safety or the health or safety of any other person;
· To county coroners and medical examiners for the investigation of deaths;
· To coordinate referrals and care with other current or former providers or facilities that we reasonably believe are providing, or have provided, healthcare to you;
· To coordinate payment with third-party payors for the services we provide to you;
· To law enforcement when we believe in good faith that the information is evidence of criminal conduct that occurred on our premises;
· If, without prior written agreement, no payment for services has been received after 90 days, your name and the balance due may be submitted to a collections agency. The full rule of confidentiality for healthcare providers in Washington can be found in RCW 70.02.
As mandated reporters, we are required by law to disclose certain confidential information, including suspected abuse or neglect of children under RCW 26.44, suspected abuse or neglect of vulnerable adults under RCW 74.34, or as otherwise required in proceedings under RCW 71.05.
For best practices, your therapist may consult with supervisors and colleagues about your case. In these instances, the information disclosed will be limited to the minimum necessary. Other health care professionals are held to the same confidentiality standards. In addition, we frequently consult with the other therapists within our Seattle Play Therapy group.
It is possible you may see your therapist in public spaces. In those cases, to protect your confidentiality, your therapist will not address you, unless you address them. To maintain the therapeutic boundaries, your therapist will not discuss therapeutic content outside the therapy room.
XII. Social Media Policy
Current legal and ethical standards do not allow therapists to engage in personal social media relationships with clients. For this reason, your therapist will not connect with or “friend” clients or their families on social networking sites, including but not limited to: Facebook, Instagram, LinkedIn, Snap Chat etc.
XIII. Client Artwork
Client artwork and pictures of sand trays are considered confidential information. As part of our practice, we take photos/screenshots of client artwork and play-based creations (including sand tray) for consulting, teaching and educational purposes. Unless you explicitly state to your therapist otherwise, by consenting to services you give your permission to SPT to take photos of and use de-identified artwork and play creations in published works or presentations for educational purposes.
XIV. Touch Policy
When in person, your therapist may use touch with your child in a safe, non-abusive, appropriate manner when playing certain games, when the child needs to be comforted, and if the child needs to be contained/kept safe. When making physical contact with children we do so only in order to meet the child’s physical and/or emotional needs. Please talk with your therapist if you have any concerns about the use of touch in your child’s therapy.
XV. Medical Records
Your child’s medical record is stored in a cloud-based HIPAA compliant Electronic Health Record (EHR) system. SPT may charge a clerical fee and an associated fee per page, for records requests consistent with Washington law (WAC 246-08-400.)
XVI. Client Rights
As a consumer of psychotherapy, it is important for you to have a general understanding of your rights under the laws of the State of Washington and to know the background of your counselor. You, as an individual or parent of your minor child, have the right to refuse any treatment you do not want, and you have the responsibility to choose a provider and treatment modality which best suits your needs.
There are benefits and risks involved in therapy. Since therapy often involves discussing troubling aspects in your life, you or your child may experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, and helplessness. Some see positive changes right away; others say that it may get worse before it gets better. It is normal for intense emotions to arise within the therapeutic relationship.
If you are dissatisfied with your therapist’s work, please bring it to their attention, as many of the conflicts that arise in therapy can be resolved through honest discussion. If you feel it cannot be resolved, it is within your rights to make a complaint to the Department of Health. A copy of the acts of unprofessional conduct can be found in RCW 18.130.180. Complaints about unprofessional conduct can be made to: Health Systems Quality Assurance Complaint Intake, Post Office Box 47857, Olympia, WA 98504-7857, Phone: 360-236-4700, E-mail: HSQAComplaintIntake@doh.wa.gov
Seattle Play Therapy, PLLC
9015 Holman Road NW #4
Seattle, WA 98117
NPI: 1699110072
EIN: 461502013