This statement is provided for your information and protection. It contains information about the types of services that I provide, my approach to treatment, my education, and my fees. If you have any questions about the information on this page, please do not hesitate to ask me.
As a counselor working towards my full licensure as a professional counselor, I will abide by its Code of Ethics.
Approach to Counseling: My overall approach to counseling comes from a holistic standpoint. The best work in counseling stems from a strong therapeutic relationship, which is a major focal point of my counseling approach. This is developed through empathy, understanding, and creating a safe space for my clients to be themselves. I draw from person-centered, Cognitive Behavioral, Emotion-focused, and creative styles of therapy. In addition, I use narrative therapy and motivational interviewing to further understand your perspective while creating the change you want. During counseling, we will work together to understand where learned behavior, cognitive distortions, and negative thought processes stem from. My goal is to strengthen self-resilience and efficacy while working within your worldview and comfort level. Together we will create stronger self-confidence and applicable coping skills that translate to all challenges within your life.
Education and Training: I earned my Bachelor of Science (B.S.) in Biology from Portland State University in Portland Oregon. I completed my Master of Science in Clinical Mental Health Counseling at Walden University in 2022. Since graduating, I have furthered my training and have received an ASD clinical specialist certification from PESI. The coursework I have completed includes techniques of counseling; psychotherapy and counseling theories; ethics and legal issues; multicultural counseling; lifespan development; assessment in counseling; group process and dynamics; diagnosis; research method and program evaluation; couples and family counseling; career counseling; counseling addictive disorders; prevention, consultation, and advocacy; crisis, trauma, and response; psychopharmacology, crisis management, and vicarious trauma. While working through my Master’s program I also became a registered behavioral technician (RBT) in the state of Oregon. This certification has allowed me to provide the applied behavioral analysis (ABA) to individuals with autism. Before this, I taught Kindergarten at a bilingual school in Portland. My experience primarily centered on working with young to adolescent-aged children and their parents. Aspects of this work included developing communication, life- skills, coping skills, confidence, behavioral management, and peer relationship skills in multiple different populations.
Continuing Education: I attend continuing education sessions that are available, to help me continue to learn and develop my therapeutic skills. In order to maintain licensure as a Mental Health Counselor Associate in the state of Washington, I will participate in 36 hours of continuing education every 2 years and attend trainings regarding subjects relevant to this profession.
Uses and Disclosures of Your Highly Confidential Information: Federal and Washington law imposes special privacy protections for “Highly Confidential Information”, which is psychotherapy notes and the subset of Protected Health Information that is related to (1) treatment of a mental illness (2) alcohol and drug abuse treatment services (3) HIV/AIDS testing (4) child abuse and neglect (5) sexual assault; and (6) genetic testing. In order for me to disclose your Highly Confidential Information for a purpose other than those permitted by laws regulating Highly Confidential Information, I must obtain your authorization.
Your Rights Regarding Your Protected Health Information:
- Right to Request Additional Restrictions. You may request restrictions on my use and disclosure of your PHI (1) for treatment, payment, and health care operations, (2) to individuals such as a family member, other relative, close personal friend, or any other person identified by you involved with your care or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While I will consider all requests for additional restrictions carefully, I am not required to agree to a requested restriction.
- Right to Receive Confidential Communications. You may request, and I will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
- Right to Revoke Your Authorization. You may revoke your authorization, except to the extent that I have taken action in reliance upon it, by delivering a written revocation statement to me.
- Right to Inspect and Copy Your Health Information. You may request access to your record file and billing records maintained by me to inspect and request copies of the records. Under limited circumstances, I may deny you access to a portion of your records. If you request copies, the clerical fee is $15. The first 30 pages will be $0.65 per page; anything above 30 pages will be $0.50 per page. However, where editing of records by a health care provider is required by statute and is done by the provider personally, the fee may be the usual and customary charge for a basic office visit, as well as applicable mailing fees if you request that I mail the copies to you. If you request a summary of your PHI, you will recieve a quoted fee per hour based upon the hourly rate for the time to complete the summary.
- Right to Amend Your Records. You have the right to request that we amend Protected Health Information maintained in your record file or billing records. I will comply with your request unless I believe that the information that would be amended is accurate and complete or if other special circumstances apply. In such cases, I will allow you to place any statements into your chart to accompany the document/statement you wish to amend.
- Right to Receive An Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made by me during any period of time prior to the date of your request provided such period does not exceed seven years after discharge/termination from service. The clerical fee is $15. The first 30 pages will be $0.65 per page; anything above 30 pages will be $0.50 per page.
- Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this notice.
Permissible Use and Disclosure Without Prior Written Consent:
A. Public Health Activities: I am legally required to disclose your PHI for the following public health activities: (a) to report health information to public health authorities for the purpose of preventing or controlling disease, injury, or disability; and (b) to report child, elderly and disabled persons' abuse and neglect to the Washington Child Protective Services or other government authorities authorized by law to receive such reports.
B. Victims of Abuse, Neglect, or Domestic Violence: If I reasonably believe you are a victim of abuse, neglect, or domestic violence, I may disclose your PHI to the Washington Child Protective Services, the Washington Department of Human Services or other governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence.
C. Judicial and Administrative Proceedings: I may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
D. Law Enforcement Officials: I may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.
E. Decedents: I may disclose your PHI to a coroner or medical examiner as authorized by law.
F. Health or Safety: I am legally required by law to use or disclose your PHI to prevent or lesson a serious and imminent threat to a person’s or the public’s health and safety. [164.512(j)].
G. Specialized Government Functions: I may use and disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances. [164.512(k)]
H. Workers’ Compensation: I may disclose your PHI as authorized by and to the extent necessary to comply with state law relating to workers’ compensation or other similar programs. [164.512(l)]
I. As required by law: I may use and disclose your PHI when required to do so by any other law not already referred to in the preceding categories.
If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your capacity or an emergency circumstance, I may exercise my professional judgment to determine whether a disclosure is in your best interest. If I disclose information to a family member, other relative, or a close personal friend, I will disclose only information that I believe is directly relevant to the person’s involvement with your health care.
It is a professional best practice for counselors to engage in either peer-to-peer or professional oversight supervision activities throughout the course of their career. As student intern still earning my degree in counseling, I am required to receive supervision by a Licensed Mental Health Counselor. My direct supervisor is Robert Johnson, LMHC, though I will also receive peer-to-peer supervision from other therapists at this clinic. During my supervision meetings I may discuss cases and treatment for the purposes of improving care and/or professional development. If I make reference to my counseling with you, I will do so in a way that disguises your identity and limits disclosure of your PHI. If such a disguise is impossible or undesirable, I will ask you to sign a waiver. If you do not agree to sign, I will not make identifiable reference to you.
Financial Terms and Conditions
Individual Counseling Fees: The hourly fee for counseling sessions is $195 with a sliding scale offered upon request. Counseling sessions are 45-50 minutes long. A no-show or late cancellation (within less than 24 hours of appointment) will require a full fee (insurance rate plus your co-pay/coinsurance or full out-of-pocket fee) payment unless there is a documented medical emergency. The fee can be waived for other emergencies if the counselor deems it okay.
Court Fees: If I am legally obligated to testify in court, the subpoenaing party will be responsible for paying my court fees. Those fees are set at the rate of $200 per hour. These fees will be charged for the following but are not limited to preparation time (including report or letter writing, filing documents at the court, or returning required calls that pertain to the case), driving time, waiting time, as well as testifying and any attorney fees or costs I incur as a result of the legal action. Please note that additional fees could apply in the event I have to interrupt vacation or personal time to appear in court for litigation. If the subpoenaing party does not pay this fee, the cost will fall to the client or the client’s guarantor.
Letter or Report Writing to Third Party/Organization: In the event that you require letters or any other form of communication in writing to institutions, companies, work, schools, courts, military, and/or other third parties for the purpose of verifying your participation or progress in counseling, as well as other actions needed on your behalf, it will be billed separately at quarter-hour increments of the agencies hourly therapy rate. Attendance verification for schools is available upon request at no charge.
Consultation Services: If a consultation meeting between the counselor and a third party is deemed necessary by the client and/or their legal guardian, the financially responsible party will be billed at $45 per 15 minutes of the consultation. A third party includes but is not limited to school counselors, licensed social workers, medical health professionals, parents & guardians, institutions, outside agencies, work, lawyers, and the military.
Requesting Records: If you require information from your records, it will be subject to a documentation fee. The clerical fee is $15. The first 30 pages will be $0.65 per page; anything above 30 pages will be $0.50 per page. However, where editing of records by a health care provider is required by statute and is done by the provider personally, the fee may be the usual and customary charge for a basic office visit.
Default: Default of the Financial Terms and Conditions of this Agreement occurs when payment is not received within thirty days of when service(s) is provided or when a fee is incurred.
Event of Default: In the event of default, we shall have the right to the following remedies, which are intended to be cumulative and in addition to any other remedies provided under applicable law or under this Contract:
1. If we incur attorney fees because of a default by Client, Client shall pay all such fees whether or not litigation is filed and all costs related to legal action including without limitation filing fees, court fees, and other service fees.
2. Venue for any such action by us shall be in Clark County, Washington.
3. If we employ a collection agency to recover delinquent charges, Client agrees to pay all collection agency and other fees, if any, charged to us in addition to other sums payable under this Contract.
4. If the collection agency incurs attorney fees because of default by Client, Client shall pay all such fees whether or not litigation is filed and all costs related to legal action including without limitation filing fees, court fees, and service fees.
5. Venue for any such action by the collection agency shall be in Clark County, Washington.
Collection Costs: In the Event of Default of the Financial Terms and Conditions of this Contract, the undersigned agrees to pay a 35% collection fee and all reasonable attorney fees.
Terms of Consent
Referrals: I recognize that not all conditions presented by clients are appropriate for treatment by this counselor. For this reason, you and/or I may believe that a referral is needed. In that case, I will provide some alternatives including programs and/or people who may be available to assist you. A verbal exploration of alternatives to counseling will also be made available upon request. You will be responsible for contacting and evaluating those referrals and/or alternatives. If for some reason I am not able to continue as your counselor at any time I will try to provide referral options and let you know how to obtain your records.
Consent to Treatment: By your signature below, you are indicating 1) that you voluntarily agree to receive mental health assessment and mental health care, treatment, or services, and that you authorize me to provide such assessment and care, treatment, or services as I consider necessary and advisable; 2) that you understand and agree that you will participate in the planning of your care, treatment, or services, and that you may at any time stop treatment or services that you receive through me; 3) that you have read and understood this statement and have had ample opportunity to ask questions about, and seek clarification of, anything unclear to you; and 4) that I provided you with a copy of this statement. By my signature, I verify the accuracy of this document and acknowledge my commitment to conform to its specifications.
This Agreement is governed by the laws of the State of Washington.
Washington State Law requires that the following statements be placed in every disclosure statement:
“Counselors practicing counseling for a fee must be registered or certified with the Department of Health for the protection of the public health and safety. Registration of an individual with the Department does not include recognition of any practice standards, nor necessarily implies the effectiveness of any treatment.”
“The purpose of the Counselor Credentialing Act (Chapter 18.19 RCW) is (A) To provide protection for public health and safety; and (B) To empower the citizens of the State of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct.”
Severability Clause: The provisions of this Agreement are separate and divisible, and if any provision hereof should be declared to be void and/or unenforceable, the remaining provisions shall be construed and shall be valid as if the void and/or unenforceable provision was not included in this Agreement.
Acknowledgment: I have read and understand the information presented in this disclosure statement, and have been offered a copy of the statement. If the client is a minor, the legal guardian (managing conservator) must sign the statement below.
I require documentation of conservatorship/guardianship. If your conservatorship/guardianship is established by a divorce decree or custody document, you are require to furnish me with a photocopy of the cause page (first page calling out the case), the page specifying conservator(s), and the signature page from the decree or document before clinical services can begin.
Email and Text (SMS) Messaging Informed Consent
If you would like to be communicated with by email or text message, I need to make sure you are aware of the confidentiality and other issues that arise when we communicate this way and to document that you are aware of these terms and agree to them.
I understand that all email messages are sent over the Internet and are not encrypted, are not secure, and may be read by others. I understand that my email communications with my therapist will NOT be encrypted and, therefore, my therapist can NOT guarantee the confidentiality and security of any information we send via e-mail. I understand that SMS messages are even less secure than email, and the same conditions apply. I understand that for this reason my therapist has advised me not to send sensitive information via email or SMS message. This includes information about current or past symptoms, conditions, or treatment, as well as identifying information such as social security numbers or insurance identification information.
By signing below I hereby give permission for my therapist to reply to my messages via email, including any information that my therapist deems appropriate, that would otherwise be considered confidential. I agree that my therapist shall not be liable for any breach of confidentiality that may result from this use of email via the Internet.
I understand that my therapist will limit SMS messages to brief inquiries or responses regarding scheduling. I understand that my therapist may at times email me information about resources that I can use as part of my treatment. I hereby consent to receive such information via email. I understand that e-mail and SMS communication should not be used for urgent or sensitive matters since technical or other factors may prevent a timely answer. I understand that if I use email or SMS to make or request scheduling changes it is my responsibility to confirm that my therapist has received my communication more than 24 hours before the appointment time being changed. If I believe I need a response within 48 hours, I will not use email but will call my therapist. If I do not receive an answer to a routine email or text message within two working days, I understand that I should call my therapist. I understand that all email and SMS communications may be made part of my permanent medical record and would be accessible to anyone given access to those records. I also understand that I may withdraw permission for my therapist to communicate with me via email or SMS by notifying my therapist in writing.
TeleHealth Informed Consent
I am aware of my options for doing sessions via telehealth or in-person.
If I choose to do sessions via telehealth:
I understand how the video conferencing technology will be used to affect such a session, and will not be the same as a direct/client/therapist visit due to the fact that I will not be in the same room as my health care provider.
I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that the telehealth system being used is a HIPPA compliant platform and have been offered this platform as the most secure option to perform the telehealth session. I understand that my therapist or I can discontinue the telehealth session if it is felt that the video conferencing connections are not adequate for the situation.
I understand that billing will occur to my insurance company as a telehealth session using the same confidentiality practices as all other sessions. I understand that it is my responsibility to ensure that my health insurance plan covers telehealth sessions and that I will be financially responsible for payment of the session in the case that my insurance does not provide coverage for this service, or if it only covers a portion of the cost.
I have had a direct conversation with an employee of A Better Way Counseling Service, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.