Welcome to ExpectGreaThings Counseling.
As you enter into the treatment process, it is important that you fully understand our policies and practices as well as your rights as a client, including the limits of your confidentiality. This form provides that information so it is important for you to read it fully before signing it and ask any questions that you may have at your initial session. ExpectGreaThings Counseling agrees to provide the undersigned client with professional counseling services based on the terms outlined below.
APPROACH TO TREATMENT/Therapist Information: ExpectGreaThings Counseling primarily uses Lifespan Integration but also draws from an integrative approach using interpersonal psychotherapy, CBT, family therapy and PCIT. The focus will be on helping you identify your individual therapeutic needs, formulating goals, which respect your personal values and culture. Therapist Lisa Madison has experience working with children, youth, adults, families, children in transitional living facilities, and foster families in counseling, educational, medical, church, and case management settings. Therapist Lisa Madison’s Counselor Registration or Certification Number: 60887881. Titles/licenses/distinctions for Lisa Madison: MA (Master of Arts in Counseling Psychology), LMHC (Licensed Mental Health Counselor), and CMHS (Child Mental Health Specialist) in King County. Therapist Lisa Madison graduated from Northwest University in 2014. Course of Treatment is individualized according to the needs of the client.
FEE INFORMATION AND PAYMENT POLICY: The cost of a 45/50-minute individual session is $135. Payment in full is due at the beginning of each counseling session through PayPal or Venmo. Please contact ExpectGreaThings Counseling directly (see contact page) for information on the payment account. Although ExpectGreaThings Counseling believes that counseling is beneficial, results cannot be guaranteed or assured.
CANCELLATION POLICY: When you make an appointment, that time is exclusively reserved for you. If you need to cancel an appointment, please do so at least 72 hours in advance. Cancellations made less than 24 hours in advance will be charged the full fee. (There are two exceptions given to this policy. Please use these for emergencies as there are only two exceptions given.)
INSURANCE REIMBURSEMENT: ExpectGreaThings Counseling is not contracted with any insurance company, which means we are considered an “Out of Network” provider. You will be responsible for the full amount of fees for the services we provide you. ExpectGreaThings Counseling does not guarantee that you will receive any reimbursement from your insurance company for your counseling services. You should contact your insurance company to determine what, if any, out of network coverage will be provided.
TELEPHONE OR EMAIL CONSULTATION/ DOCUMENT PREPARATION: Time spent on telephone or email consultations in excess of 10 minutes may be billed on a pro-rated basis at the rate of your therapist’s individual session fee. This includes consultations with you, or other healthcare professionals that may be involved in your care. Additionally, time spent preparing or sending documents for you or on your behalf will be charged on a pro-rated basis in addition to any mailing costs incurred. ExpectGreaThings Counseling does not write letters for court cases.
TRANSFER PLAN In the unlikely event that your therapist is no longer able to provide services, you will be provided with a referral for another therapist.
COURT / MEDICAL EVALUATIONS It is our policy that we do not go to court for clients. As therapists, we believe it is our role to support you in your healing process and it is outside the scope of our practice to make psychological evaluations since we are not trained evaluators. Similarly, we are not trained to evaluate your fitness for work to make recommendations regarding a Family Medical Leave of Absence (FMLA) or disability claim given that we are not trained psychological evaluators.
LIMITS OF CONFIDENTIALITY: ExpectGreaThings Counseling has access to client files and personal information. ExpectGreaThings Counseling’s policy regarding release of information is that all information given by a client to their therapist is confidential and will not be revealed to any person or agency without the client’s written release, or without other substantial justification for such release (listed below). It is the policy of ExpectGreaThings Counseling to uphold the maximum client confidentiality possible, under the laws of Washington State. There are certain circumstances in which Washington State law requires healthcare professionals, including licensed mental health professionals, to disclose information about a client to other individuals or agencies, with or without that client’s permission. This includes the following circumstances: 1. If a therapist is aware that a client intends grave bodily harm to any other person. 2. If a therapist is aware that a client intends grave bodily harm to himself or herself. 3. If a court of law issues an order requiring the disclosure of information. 4. If a therapist has reasonable cause to believe that abuse or neglect of a child has occurred. 5. If a therapist has reasonable cause to believe that abuse or neglect of a dependent adult or developmentally disabled person has occurred. When such disclosures are required, it is the policy of MCS to make a sincere effort to inform the client that such a disclosure is going to be made prior to making the disclosure. Additionally, a healthcare provider or healthcare facility may disclose health care information about a patient without the patient’s authorization to the extent a recipient needs to know the information, if the disclosure is: 1. To a person who the provider reasonably believes is providing healthcare to the patient (WA Rev. Code 70.02.050(1)(a)). 2. To any person if the health care provider or healthcare facility reasonably believes that disclosure will avoid or minimize imminent danger to the health or safety of the patient or any other individual (WA Rev. Code 70.02.050(1)(c)). 3. For payment, including information necessary for a recipient to make a claim, or for a claim to be made on behalf of a recipient for aid, insurance, or medical assistance to which he or she may be entitled (WA Rev. Code 70.02.050(1)(d)).
STAFF CONSULTATION: ExpectGreaThings Counseling may have more than one counselor in the future. When this is the case, the team will consult freely about clients at ExpectGreaThings Counseling keeping the privacy rights contained in this document. In addition to this, staff at ExpectGreaThings Counseling may also consult with a team of consults and other Licensed Mental Health Clinicians selected that will also be bound to the privacy rights in this document, in order to provide the highest service available for the clients. This consultation allows clients to benefit from diverse clinical backgrounds and perspectives. Your signature on this disclosure indicates your permission to do this.
TERMINATION: Once you have terminated treatment, your client record will be closed and held for a period of 5 years. If at any time you choose to return to therapy, your file can be re-opened. If you decide to discontinue treatment without notifying your counselor, we will make an attempt to contact you. After 30 days of no contact, we will assume you have terminated treatment and we will close your file.
NOTICE OF PRIVACY PRACTICE: You should be aware that, pursuant to HIPAA, we keep Protected Health Information about you in a professional record. It includes information about your name, dates of service, fees, a description of the services provided, your diagnosis, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, and any reports that have been sent to anyone, including reports to your insurance carrier. You may examine and/or receive a copy of your Clinical Record if you request it in writing, except in the unusual circumstance that we believe disclosure could cause danger to your safety or to that of any other individual. A copy fee may apply. You have the right to: *Request restrictions on how we use and share your health information. We will consider all requests for restrictions carefully, however, we are not required to agree with all of the restrictions. *Request that we use a specific telephone number and address to communicate with you. *Request amendments or additions to your health record. *Request an accounting of certain disclosures of your health information made by us. *All of these requests must be made in writing. You may also file a written complaint with the Office of Civil Rights of the U.S. Department of Health and Human Services in Olympia, Washington.
USE OF TECHNOLOGY If you choose to use technology (primarily email or text) to correspond with us, it is important to understand that your information is not secure in cyber space as we do not have an encrypted website. We often schedule with clients via text and email, so we need to know if you are comfortable with this. Please give your consent below:
I consent to corresponding with ExpectGreaThings Counseling via technology that is not secure _______.
I do not consent to corresponding with ExpectGreaThings Counseling via technology that is not secure _______.
Your signature below indicates that you have read this therapy contract, asked any questions you have with your therapist, and agree to its terms. It also serves as an acknowledgement that you have received and read our disclosure statement including the Limits of Confidentiality, and a Notice of Privacy Practice HIPAA summary about your privacy protection and patient rights with regard to the use and disclosure of your protected health information.
Client’s name (Printed/ Date ______________________________________________________
Client Signature/Date ____________________________________________________
Therapist’s signature below indicates that he/she has reviewed this contract and disclosure form with the above named client/clients and has addressed any and all questions or concerns.
ExpectGreaThings Counseling Therapist’s Signature/Date ____________________________________