Laura Stone, LMHC 174 Roy Street, Suite B, Seattle, WA Telephone:

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1 Disclosure Statement, Privacy Policies, Financial and Payment Information Welcome I look forward to working with you. In order to simplify the beginning of our work together I have compiled the information below. I ask that you review it, sign on the two last pages, keep one copy and return the signed copy to me prior to beginning our first session. If you have questions that are not addressed below, please let me know. Appointments & Cancellation Policy: Appointments are minutes in length. I hold your appointment time exclusively for you. If you are unable to keep your appointment for ANY reason, please contact me (voice mail is okay) with at least 24 hours notice to cancel or reschedule. Otherwise you will be charged for the time you have reserved. If you have a regular appointment scheduled with me and you plan to be absent for more than a week I will not be able to hold the slot for you until you return; you and I will need to discuss what appointment times are available when you resume your sessions. (These policies are not intended to be punitive but rather to protect my business and income, so that I may continue to be here to provide services.) Fees and Payment Policy: The current fee is $120 per minute session payable in full at the time of each session. This fee is subject to periodic increases, and I will provide you with 30 days notice of fee changes. If you are using an insurance for which I am a contracted provider you will be responsible for paying your co-pay and any co-insurance amount at the time of each session. Please inform yourself of what these rates are prior to starting sessions. As soon as I receive payment from your insurance company each month I will inform you of any residual amounts you may owe. (See information on insurance below). I do not send out bills. You are responsible for paying each time you come in and for tracking any balances you may owe. If you do develop a balance I ask that you pay it by the end of the month in which it has occurred. If you require a statement of your account I will provide you with one. If you cannot afford to pay the full fee, please discuss with me the availability of a sliding fee scale prior to your first appointment. If you end therapy with an outstanding balance owed, I will expect you to pay it immediately. If you end therapy prior to your insurance company s last reimbursement to me for your sessions, I will notify you ASAP of any balance you owe, and I will expect payment immediately. If you refuse to pay your debt, or have outstanding debt for a period of over 60 days, I reserve the right to give your name, contact information and the amount you owe to a collection agency. Insurance: You may have insurance coverage for mental health care. If you would like to use it to cover all or part of the cost of your therapy I advise you to contact your insurance company before our first appointment to verify your rate of coverage, the number of covered sessions annually, the amount of your co-pays, and any deductibles that need to be met before coverage begins. Your plan may require

2 preauthorization ask when you call them. I also suggest you become informed of issues regarding the confidentiality of your records if you choose to use your insurance (i.e. insurance companies cover services that are deemed medically necessary, meaning a diagnosis will be required and will become part of your medical records. Insurance may cover a limited number of sessions per diagnosis). In general, I will not directly bill your insurance company for you (with the exception of Regence, Premera, and First Choice health plans, with whom I am a contracted provider). I will provide you with the information necessary to file your own claims. Please note, while you are using your insurance to cover any part of the cost of your sessions, you will not be eligible for any reduction in the rate per session. Note also that insurance companies will not cover the cost of missed appointments. Please also understand, even if I am contracted with your insurance company, you are ultimately responsible for full payment, including any and all portions that are not covered by your insurance for any reason. Phone Calls, After Hours Contact: I carry a cell phone that functions as my business phone. You may call me at any time. If I am not available, you may leave a voice mail message and I will return your call as soon as possible. If you feel yourself to be in crisis please indicate so in your message. I check voice mail messages fairly often throughout the day and less frequently on holidays and weekends. If you have concerns about these arrangements, please let me know. Brief telephone contact will not be charged. Extensive calls, reports and written information on your behalf that you request may be charged at a prorated hourly rate. and Texting Policy: You may wish to me with information or requests. Please also be aware that is not a completely secure form of communication, in that there is a possibility of content being accessible to a system administrator, hacker or other third party. Please understand that although I will do my best to answer your s at your request, I will limit our communication from my end to scheduling details or other non-clinical information. If you need to speak with me about your treatment in more detail, please call or schedule an appointment. If you need to contact me immediately, please call instead of texting me texting is not a secure form of communication. If you send me a text message I may not read it in a timely manner. However, if you must contact me and you have no other means, please limit texts to scheduling information, such as, I am running 5 minutes late. Social Media Policy: I maintain a minimal private social media presence, and at this time I do not have a professional Facebook page. I maintain a Linked-In professional profile. I maintain a professional website, which contains a contact page for new clients to contact me regarding scheduling initial appointments. I am listed on several professional websites. I do not, under any circumstances, invite or allow access to my private social media. I will not accept friend requests, or similar requests for contact with clients, past or present, because doing so could create a beach of your confidentiality as well as violate therapeutic boundaries. I will not seek out or pursue clients in any way via social media, Google searches, or other internet search except in the event of a life-threatening emergency and if I do

3 not have your direct contact information. If you use location services on your phone, others may become aware of your location when you are in my office; please be aware of how this impacts the limits of your confidentiality. My Background, Education and Credentials: I am a Licensed Mental Health Counselor in the State of Washington, license number LH I have an undergraduate degree and background in visual arts. I received my Master of Arts Degree in Psychology and Mental Health Counseling from Antioch University in Seattle in I also hold certificates in Foster Care And Adoption Therapy, and in Attachment And Trauma Focused Therapy. I have worked in the field of social services since My work history includes private practice since 2003, as well as clinical positions held at several local mental health clinics, including Highline West Seattle Mental Health Center (now NAVOS), Seattle Children s Home, Community Care for Children, and Family Services of King County (now Wellspring Family Services) between 1997 to I have extensive experience working with adults, adolescents, children, families and couples. I have received multiple trainings in child therapy, play therapy, and art therapy. Approach to Treatment: I am trained in psychodynamic theory and technique, as well as attachment-based theory and practice. My specific mode of therapy will vary and is in part determined by the needs and issues of the client. The initial focus will be on assessment and developing a mutual understanding of the issues that bring you and/or your family in for therapy. We will create a plan for the sessions that identifies the goals and an initial time frame for our work together. With individual adults, I work primarily from an insight-oriented psychodynamic approach and incorporate elements of cognitive and behavioral therapy. In general, this means we will talk - about your emotional experiences, both past and present, that are sources of concern to you. Over the course of the therapy process we will work to understand more about what has prevented you from making desired changes, as well as what is working for you. Through paying attention to what is happening in your life, as well as in the therapy process itself, we will allow you to better understand yourself and others, release old patterns, make clearer decisions and create a more satisfying life. Therapy is an opportunity to experience a healthy working relationship, based on reflection, thought and commitment to your development and process of growth. My role will be to listen, reflect, and help to illuminate whatever you bring to the sessions. Your willingness and focus on self-awareness and your work between sessions are essential elements of your work together. In working with young children, I frequently make use of play and art therapy techniques. Children tend to communicate and seek resolution through their play and art, and many conflicts and issues may be addressed by working with children through these natural processes. In work with traumatized children and children with attachment issues, parents can be expected to be heavily involved in their young child s therapy process and can usually expect to sit in on and participate in their child s session. We may work dyadically, meaning we will work on the dynamics of the relationship between you and your

4 child. Parents are encouraged to offer insights, ask questions and consult with me often. I will also be scheduling separate parent sessions when appropriate. In working with young children with attachment issues, I may direct the child in certain kinds of activities and play, along with the parent, that are designed to strengthen attachment between parent and child. These activities may be very hands on, i.e. encouraging holding and feeding, rocking, etc. No child will ever be held in a coercive way. Sometimes a very upset child may be held or restrained, if they are presenting a danger to themselves or others, until they can regain control of their body. Restraint is never used as a therapy technique but is only done to prevent injury to the child or another person. With older children and teens we may do a combination of playing and talking, and parent involvement will be defined according to the issues and goals and age of the child, as well as his/her abilities to process and communicate. If you are a parent of a child 13 or older, please know that your child has a legal right to refuse treatment, and must consent to their own treatment. Please understand your child may need to speak to or meet with me privately, and may discuss sensitive issues in their life with me without you present. I will not disclose such information to you without your child s consent. I will let you know if I judge your child to be in mortal danger. I attend a consultation group monthly where I discuss cases with other professionals, while maintaining the anonymity of the client(s). When the client is a child I may request to contact other systems with which the child is involved, including school staff, day care staff, pediatricians, social workers, etc. in order to gain a more complete picture of the child s world as well as to provide recommendations and assistance as appropriate, and I will only make such contract with the written permission of the child (over 13) or of the parent/guardian (under 13). Your Legal Rights, Including Privacy & Confidentiality (Last updated 9/21/16): You have the right to refuse and/or end treatment at any time. Parents and guardians of children under 13-years-old, who have legal health decision-making rights, may refuse and/or end their child s treatment at any time. You have a right to get a copy of your paper or electronic medical record. You have the right to confidentiality, including the fact that you are or have been a therapy client, except as explained below. I think of this right to privacy as being your most important right as a client. Despite numerous legal exceptions to confidentiality that have been enacted both on the federal and state level in the past few years, it is my policy and practice to keep confidential all information that you discuss with me, and to not reveal it to any other person or agency without your written permission. Should there be an instance where I ask you to provide me with written permission to reveal something about you or our work together to someone else, and you grant me permission to do so, you also have the right to revoke that permission. The possible legal exceptions to this policy might be: * Where there is reason to suspect the occurrence of abuse or neglect of a child, a dependent adult, or a developmentally disabled person;

5 * Where there is a clear threat to do serious bodily harm to yourself or others; * In response to a subpoena issued by the Secretary of Health that is associated with a regulatory complaint. * I may share information about you if a state or federal law requires it. If you are involved in some legal action, it is possible that a court order might require that I provide the court with evidence relating to your sessions. If this should occur, it would be my preference to work with you to prevent or limit such disclosures. If you are being seen with another person present, I can make a request that each person respect the other s rights to privacy, but I cannot guarantee this request will be honored. As an ongoing part of my clinical development and in pursuit of providing you with the best care, I consult regularly with a group of colleagues who are Licensed Social Workers and/or Licensed Couple and Family Therapists and/or Licensed Mental Health Counselors. Should I discuss your therapy with my consultants, I will only relate the content of our work together. You will not be named, nor will I share any details of your life that might identify you. If you have any concerns or questions about this please let me know. I do keep a record of dates of service and fees as well as notes on assessment and notes of each session to assist me in my work. You have the right to review your record if you desire. You also have the right to ask me to correct the record if you believe the information is in error. A copy of your corrections to my record will be placed within your record at your request. You have the right to request restrictions on certain uses and disclosures of your healthcare information. For example, you may request that I speak with your primary care doctor, but not want me to acknowledge all that you have told me. As a treating clinician, I am legally obligated to agree to your request for restriction, but if I believe sharing the information is required for optimum care or safety, I would want us to make a mutual decision about how to proceed. You have the right to confidential communications regarding your private healthcare information, including the fact that you are my client. For example, I will not divulge clinical information to anyone who answers your home or work phone (should I have occasion to call you), and/or you can request that I use an alternate mailing address if communication by mail is necessary. You have the right to request a written accounting of the disclosures I may have made of your healthcare information (if any). The law allows many exceptions to this accounting, but my preference and practice is for you to know of any disclosures before they occur. You have the right to have this written copy of my Disclosure and Privacy Notice. You have a right to choose someone to act for you in the terms of this notice. In addition to your rights, you also have some choices: No part of your Private Health Information will be shared without your permission for *Marketing purposes *Sale of your information *Most sharing of psychotherapy notes

6 *Although it is legal for me to contact you for fundraising efforts, this is not my practice and you may tell me not to contact you again. You may choose to tell me how to: *Contact you (or not) by *Share information with your family, close friends, or others involved in your care *Share information in a disaster relief situation. If you are not able to tell me your preference, for example if you are unconscious, I may go ahead and share your information if I believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to your health or safety. My Responsibilities Regarding Health Information: How I typically use and disclosure your health information: *To treat you *To run my practice for example, I may use your information to manage and improve your treatment and services, and contact you when necessary. *To bill you for services rendered *To bill your health insurance company for your services rendered to you I am required by law to abide by the terms of this document, though I am also legally allowed to change the terms, and to make the provisions of any modified version effective for all private healthcare information in my care. You may request that a copy of a modified version be given or sent to you. I am required to let you know promptly if a breach occurs that may have compromised the privacy or security of your information. Complaints: If you believe that I have violated your privacy rights, you may file a complaint in writing with me, and/or with the Secretary of the Dept of health and Human Services. I will NOT retaliate against you for filing such a complaint. You may contact the Department of Health at , or by writing to Department of Health, Health Professions Quality Assurance Division, P.O. Box Olympia, WA You can request a copy of the acts of unprofessional conduct, or access this information online at

7 Client Acknowledgment and Consent to Treatment: I have read the preceding Disclosure and the Notice of Privacy Policies, and have been given an opportunity to ask questions clarifying its contents. I understand the contents of this document and my rights as a client. I agree to the terms of this agreement and do hereby request and consent to treatment by Laura Stone, LMHC. Child Consent: I/We the undersigned parents or legal guardians of do hereby request and consent to the treatment of our said child by Laura Stone, LMHC. Client or Guardian Signature Client or Guardian Signature Provider Signature

8 Please Initial All That Apply: Financial Agreement I have read and understand the Policies on Fees and Payments. I agree to pay $120 per session for professional services received from Laura Stone, LMHC, in full, at the time that the service is rendered. I have read and understand the Policies on Insurance. I am using insurance, for which Laura Stone, LMHC, is a contracted provider, to cover part or all of the cost of my therapy sessions. I agree to pay any and all co-pays and co-insurance amounts not paid for by my insurance plan. I understand I will be responsible for full payment ($120 per session) unless and until my insurance pays for a portion of my sessions. I am using insurance to cover part or all of the cost of my therapy sessions. I authorize Laura Stone, LMHC, to bill my insurance carrier for services received. I also authorize my insurance carrier to direct payments to Laura Stone, LMHC. I have read and understand the Policies as stated in this form in regards to Billing. I understand I will be responsible for keeping track of my own balance owed and may not receive a bill for services unless I request a statement of my account. I have read and understand the Cancellation Policy, requiring me to provide 24 hours notice for all missed appointments, and I agree to pay the full fee for any and all appointments missed without 24 hours notice. I understand that if I end therapy with a balanced owed, I must pay the balance immediately. Further, I understand unpaid balances over 60 days will be submitted to a collection agency, and that I will be responsible for the balance owed as well as any costs associated with the collection of my account balance. Client or Guardian Signature Client or Guardian Signature Provider Signature