Counselor Disclosure and Informed Consent

Effective date: 2024-11-04

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent provides a framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by signing at the end of this document.

THE THERAPEUTIC PROCESS

Counseling is a collaborative process with an ongoing relationship between a client (you) and a mental health counselor (me). The counseling experience is intended to support you in establishing new behaviors and in working towards wellness.

The most important aspect of therapy’s success is you. Client factors, such as willingness to experiment and work between sessions, your life context, strengths, and relationships account for up to 85% of change in therapy. Because of this, I prioritize building a forward-looking, strengths-based and collaborative relationship. My goal is to help you progress towards achieving your goals. Together, we will regularly assess your progress, and if improvement is not happening to your satisfaction, I will provide a referral to another professional.

RISKS OF THERAPY

Therapy is the Greek word for change, and there is always a chance for change to be painful. You may learn things about yourself that you do not like, and may need to face feelings of fear, sadness, sorrow, anxiety, or pain. You may also find that as you come to better understand yourself, your relationships with others shift. One risk of therapy relating to relationships is the possibility of the dissolution of some relationships (i.e., a divorce or a breakup). While not common, some people do deteriorate with therapy. Some variation is expected early in therapy, but if you find you are consistently feeling worse, please raise that in therapy. We can then discuss potential different options, including a referral or discontinuing therapy.

LENGTH OF THERAPY

Therapy sessions are a 50 minute clinical hour instead of a 60 minute clock hour so that I may review my notes and assessments on your behalf. I also use the last few minutes of each session to use a 3-question assessment on how the session went so I can make adjustments as we work together. This feedback helps me keep your voice and needs central to our work, and helps me be accountable to you. It also has been shown to make a difference in how effective clients find therapy.

A common question is how long therapy will take. This is difficult to answer as therapy depends on a variety of factors. Additionally, clients’ goals often change as therapy evolves, organically lengthening the process as we work towards those new goals.

EDUCATION & QUALIFICATIONS

I have a Masters of Counseling degree from Saybrook University. I previously obtained a Masters of Science in Computer Science from the University of Texas at Austin and worked for 20 years in the software industry in a variety of technical and people management roles. I regularly take continuing education in a variety of psychology, counseling, and neuroscience topics to learn more about the latest techniques and science of emotions, brains, and relationships.

I am a Licensed Mental Health Counselor Associate (LMHCA) in Washington state. My Washington state license number is MC 61555549. I am a licensure associate under the supervision of an approved supervisor.

THERAPEUTIC ORIENTATION

I trained in a humanistic style and primarily practice common factors therapy, focusing on empathetic listening, building an honest relationship, understanding emotional and cognitive processes, and regularly evaluating progress. As a technical eclectic, I use what works, regardless of the approach. In sessions, we may use ACT, CBT, psychodynamic, Solution- focused, DBT, mindfulness, mindful movement or art or play therapy techniques.

SUPERVISION & CONSULTATION

I seek ongoing consultation from colleagues in order to provide you with the best services possible. I may disclose information about you in consultation with colleagues, in which case I will limit the information I disclose to the minimum amount necessary.

I have a supervision agreement with Alycia O’Conner (LCSW, LICSW, CACD III) and I may disclose information about your counseling session as part of ongoing supervision.

ACCESS TO RECORDS

I have an agreement with Shelterwood Collective, PLLC to serve as my records custodian. They have access to my client files, in accordance with all applicable state and federal laws or rules, in order to make appropriate notification and referrals in case I am temporarily or permanently incapacitated. If you do not consent to Shelterwood Collective accessing your file in case of my incapacity, please let me know so that I may make alternative arrangements.

EMOTIONAL SUPPORT ANIMAL LETTERS

I do not write letters for emotional support animals. If this is something you seek, we can discuss alternate options or referrals.

VIDEO RECORDING POLICY

As part of my supervision, I ask for your consent to record our sessions. The goal of this practice is to enhance my competence and your care. The content recorded is held to the same laws of confidentiality as other material produced during our therapy sessions. You have the right to ask me to stop or delete the recording. Recordings will be destroyed after one month. You may revoke your permission at any time.

COMMUNICATION & EMAIL

It is my policy to use email or text for scheduling, financial arrangements, and to check in if I have not heard from you as expected. Because of the nature of electronic communications, I cannot guarantee the confidentiality of information transmitted in this manner. Please know that these communications may become part of your legal file if the court were to request records.

YOUR RIGHTS AS A CLIENT

This is your space. I invite you to bring any and all questions, concerns or frustrations you may have during the course of therapy. If you would like something different in our time together, please ask. You have the right to refuse any treatment you do not want, and the responsibility to choose a provider and treatment modality which best suits your needs. You may engage in therapy for as long as you like. You may, at any time, change your goals for therapy or choose to end our relationship, no matter where you are in the process of goal achievement. I respect and promote your right to make your own decisions. I believe doing so is part of the healing process in therapy. Should it become apparent that I am not able to meet your needs in counseling, I will readily provide you with referrals to other therapists.

You have the right to a relatively comfortable, safe, and professional environment where I consider your best interests my priority. I maintain the following practices regarding professional relationship boundaries:

I will not have a social relationship with you outside of my office, even after we have ended our therapeutic relationship. This is a professional boundary, not one of not caring.
I will not, at any time, have personal physical or sexual contact with you.
If we encounter each other outside of therapy, I’ll maintain professional boundaries, may briefly say hello (if in a space where it would be awkward to not do so), and won’t acknowledge how we know one another unless you do first.

Adding clients as friends or contacts on these social media can compromise the professional relationship as well as client confidentiality and the privacy of the therapist and the client. Because of that, I ask that you do not send friend requests, messages, or follow my personal accounts on social media. To the extent I can recognize usernames or faces, I do not accept friend or contact requests from current clients on any personal social networking sites. In some instances where we may be in shared communities online, I might block your account (and you should feel free to do the same with mine) so that I reduce the chance of seeing posts containing information you may not want to bring into the therapy room.

I do maintain a professional social media presence that I may use to provide information to the general public and to clients. Please do not use any professional social media platform as a mode of communication with me. In addition, please understand that your decision to connect to my professional social media presence may result in the disclosure of our professional relationship.

YOU HAVE THE RIGHT TO CONFIDENTIALITY

I am bound by law and professional ethics to protect client rights to confidential communications regarding their involvement in counseling. All issues discussed in the course of counseling are strictly confidential. You do not have the responsibility to maintain confidentiality and are free to discuss your therapy with anyone you wish.

Your participation in therapy, the content of our sessions, and any information you provide to me is protected by legal confidentiality. Some exceptions to confidentiality are the following situations in which I may choose to, or be required to, disclose this information:

If you give me written consent to have the information released to another party;
With your authorization, to effect billing of a third-party payor for the services I provide to you;
In the case of your death or disability I may disclose information to your personal representative;
If you waive confidentiality by bringing legal action against me;
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 I reasonably believe that disclosure of confidential information will avoid or minimize an imminent danger to your health or safety or the health or safety of any other person;
If, without prior written agreement, no payment for services has been received after 90 days, the account name and amount may be submitted to a collection agency.

As a mandated reporter, I am 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.

SHARED COMMUNITIES AND CONFIDENTIALITY

The nerdy, queer, polyamorous, kink, arts, re-enactment, and Burning Man communities in Washington can be small and interconnected. This can sometimes create additional risks around confidentiality. We might attend the same events, share social or romantic circles, or I might provide therapy to people you know or have been in a relationship with. I am committed to maintaining confidentiality of all parties I work with and working ethically. If you have any concerns, please bring them up so we can discuss how to manage them, including the option of a referral to another therapist. Note that in the same way I cannot confirm to others that you are a client, I cannot confirm to you who my other clients are.

GROUP COUNSELING

If you are participating in group counseling, it is important you understand that I will adhere to the ethical and legal requirements of confidentiality. However, I cannot ensure that the other group counseling participants will maintain confidentiality about your therapeutic experience including content discussed within the group counseling session.

FAMILY AND RELATIONSHIP COUNSELING

If you are seeking family or relationship counseling, it is important you understand that I will adhere to the ethical and legal requirements of confidentiality, however, I cannot ensure that you or the other participants in the family or relationship counseling will maintain confidentiality about your therapeutic experience including content discussed within the counseling session. In addition, in the case of family or relationship counseling, the entire treatment record will be available to any and all participants in the family or relationship counseling, and all participants must consent to any authorized third party disclosure. I cannot maintain secrets between members of the family or relationship. In such situations, if we cannot find a clinically appropriate way for you to disclose the information to the other member(s) of the family or relationship, I may need to terminate the clinical relationship and refer you to another provider.

WORKING WITH MINORS

If you are the parent or guardian of a minor who is seeking treatment, please know that under Washington State law, any child age 13 or older can independently consent to mental health treatment without your permission. In addition, parents or guardians may not generally access the treatment record of a client aged 13 or older without that client’s written permission. If you are 13 years of age or older, you have the legal right to seek mental health treatment without obtaining permission from a parent or guardian. Under certain circumstances, the parent of an adolescent may consent, on behalf of the adolescent, to a mental health or substance use assessment and limited treatment.

I am not able to provide a recommendation, evaluation, or opinion, in any legal forum relating to separation, divorce, child custody, visitation, or parenting plans. I will need to be provided with a copy of any parenting plan, custody orders, or any other similar documents, including any changes or revisions made during the course of treatment. It is generally necessary that both parents or legal guardians consent to treatment of their minor child.

COMPLAINTS

If you have any concerns about your experience or if you believe that I have acted in an unprofessional or unethical manner, I encourage you to let me know so that we may discuss the situation and I can have the opportunity to address or resolve the problem. A copy of the Washington Acts of Unprofessional Conduct can be found in RCW 18.130.180.

If you think that discussion has not worked or if you feel uncomfortable bringing this directly to me, for any reason, you are encouraged to contact the Department of Health:

Health Professions Quality Assurance, PO Box 47869, Olympia, Washington, 98504
Email: HSQAComplaintIntake@doh.wa.gov
Phone: (360) 236-4700

YOUR RESPONSIBILITIES AS A CLIENT

SCHEDULING

I agree to adhere to our established session times and I expect you to do the same. We should plan to begin and finish all sessions on time. If you’re more than 15 minutes late to a session, I’ll assume that the session is canceled, and you will be responsible for the full session fee. If I’m late to a session, you may choose whether to have the session as scheduled for the same fee, or to postpone it to a later time.

FEES & BILLING POLICIES

You are agreeing to begin a therapeutic relationship, which involves the following financial responsibilities. The cost of psychotherapy is determined by the length of session. My fees are as follows:

50-minute psychotherapy session — $175 (90837)
50-minute intake session — $175 (90791)
50-minute relationship session — $200 (90847)
80-minute relationship session — $250
8-week group session — $480

I provide psychotherapy in person and via telehealth. The cost for either format is the same, based on the session length and type outlined above. I may have a limited number of sliding scale appointments available based on client financial need. I am happy to discuss this with you further if you feel this might apply to your situation.

I work with clients on a weekly cadence. The frequency of sessions may be more or less than once per week, depending on your clinical needs.

Payment is due at the beginning of each session. You will need to add a debit or credit card on file and authorize autopayment. Cards are typically charged at the beginning of the day of the appointment, unless other arrangements have been agreed to by both parties.

I do not voluntarily participate in legal proceedings. If my participation is requested or required in a legal matter, my regular hourly rate applies to all preparation, participation, travel, and waiting times.

Services are expected to be provided generally on a weekly basis until treatment is terminated. Additional services may be recommended. This estimate of your costs is only an estimate, and your actual charges may differ. You have the right to initiate the patient–provider dispute resolution process if the charges you are actually billed substantially exceed the expected charges in this estimate. This estimate of costs is not a contract and does not obligate you to obtain clinical services from me.

RECORDS FEES

The fee for any other paperwork completed on your case outside the regular course of treatment is my hourly rate, billed in half hour increments. This includes writing a report, submitting a letter, filling out FMLA paperwork, and making recommendations to schools or workplaces. This work will only be done after you specially request it and after I discuss with you how long the task will take. I may charge you an administrative fee for copies of your record as permitted by WAC 246-08-400.

ATTENDANCE

Since this time is reserved for you, it becomes your financial responsibility. You can cancel or reschedule a session with at least 24 hours notice to me in advance, without a change fee. Any cancellations within 24 hours are subject to the full session fee.

Consistency and predictability of our sessions is a key part of the clinical process. I may need to terminate the current episode of care if you are unable to maintain consistent participation in scheduled sessions, typically meaning no more than 3 late cancellations or no-shows within 6 months.

No refunds will be issued for counseling sessions after the session has occurred.

BILLING ADMINISTRATION

I am an independent practitioner working in association with Shelterwood Collective, PLLC. All Shelterwood Collective practitioners are independent provider businesses who are solely responsible for the clinical services they provide. All services rendered are representative of each individual practitioner’s license, independent business, and practice style. We share values, resources, and community in the spirit of providing ethical, professional healing services.

INSURANCE [IN NETWORK]

I am an affiliate of Shelterwood Collective PLLC (TIN #47-4860247 / NPI-2 #1538663604). Through their group contracts I provide in-network mental health care with Premera and Lifewise. Insurance companies and other third-party payers may require that I provide them with information regarding the services I provide to you. This information may include the type of service provided, the dates and times of service, your diagnosis, treatment plan, a description of impairment, progress of therapy, and case notes and summaries. If you do not want me to provide your confidential information to your insurance company, let me know so that we can discuss alternatives.

You remain ultimately responsible for paying any deductible, copay, or other out of pocket expenses that your insurance provider may require. You also remain ultimately responsible for paying any claims that your insurance provider may reject.

INSURANCE [OUT OF NETWORK]

For insurances I am out-of-network for, I do not bill insurance for the services I provide to you. You may choose to submit a receipt (a “superbill”) for our sessions for reimbursement from your insurance company. It is your sole responsibility to determine what reimbursement you may be entitled to. You remain ultimately responsible for paying any claims that your insurance provider may reject. In order to be reimbursed for services, insurance companies and other third-party payers may require that I provide them with information regarding the services I provide to you. This information may include the type of service provided, the dates and times of service, your diagnosis, treatment plan, a description of impairment, progress of therapy, and case notes and summaries. If you do not want me to provide your confidential information to your insurance company, let me know so that we can discuss alternatives.

COMPLETION OR TERMINATION OF THERAPY

You may end our counseling relationship at any time, and I will be supportive of that decision. If you choose to end the counseling relationship, I may offer a termination session with you to close out our work together. While such a session can be beneficial for closure, it is also completely optional. If, without having made prior arrangements, I have not heard from you in 30 days I will assume that you would like me to terminate our current episode of care and close your active clinical file. In such cases, we may discuss the possibility of re-opening the file and initiating a new episode of care upon your request.

EMERGENCIES

I provide non-emergency clinical services by scheduled appointment. If you are in a crisis or an emergency situation, please call 911 or go to your nearest emergency room. You may also contact King County’s Crisis Connections at 206-461-3222 or 1-866-427-4747.

By signing this document, you are attesting that you have received, read, fully understand and consent to the disclosures, terms, and conditions above, that you have received a copy of your HIPAA Notice of Privacy Practices, have read and fully understand these rights, and have been given the opportunity to ask questions. By signing this document, you are attesting to your consent to participation in counseling services provided by Jonobie Ford, LMHCA.