Informed Consent for Counseling Services: Treatment, Disclosures, Payment Information, & Privacy Rights

Bellefield Office Park ~ Cedar Bldg | 1400 112th Ave. S.E., Suite | Bellevue, WA 98004


I am a master’s level Licensed Mental Health Counselor (LMHC), Licensed in the State of Washington, LH60210343. I am an approved licensed mental health counseling supervisor in the state of Washington, providing clinical supervision to new therapists seeking full licensure. I am intensively trained in Dialectical Behavioral Therapy and the trauma treatment EMDR (Eye movement desensitization and reprocessing).


There are few known risks associated with Counseling. However, some people report a heightened emotional awareness which can bring on stronger emotions. In some cases, people feel more depressed and have thoughts of suicide. Also, as you grow and learn things about yourself, your relationships with others may change.


Clients have the right to: 1) be treated with respect and dignity in the therapeutic environment; 2) confidentiality and privacy; 3) refuse or terminate counseling at any time; 4) not be discriminated against; 5) obtain a copy of client records or request to amend a record; 6) to file a formal complaint against the therapist. If the client desires to terminate the counseling contract, it is helpful when this is discussed in advance, so that proper closure, including referrals, when appropriate, can be provided.


I typically see clients once a week unless sessions are arranged otherwise. Clients may schedule appointments as needed according to their therapeutic goals. Treatment may last anywhere from short term (10-12 sessions) to long term (up to several years), depending on client symptom relief and perceived change. Clients receiving DBT treatment will be in individual therapy 1 time per week and in group skills training 1 time per week. Clients who do not commit to both individual therapy and skills training are not in evidence based DBT treatment. I use, when appropriate, EMDR Protocols in treatment of distressing and unresolved memories. Clients have the right to refuse treatment at any time. Counseling is a process of change and will not happen overnight. A client may choose to continue maintenance counseling as desired, unless it is determined that sessions are no longer helpful or otherwise unnecessary. I help clients develop a treatment plan to track their progress in life domains and create goals that are meaningful and measurable. Exceptions made at discretion of therapist.


I maintain the confidentiality guidelines of the Washington Administrative Code (WAC), the Health Insurance Portability and Accountability Act (HIPAA) and the American Counseling Association (ACA). I will not disclose any personal or identifying information to anyone outside the therapist-client relationship without a client’s written authorization. Specific to child therapy, I will not testify in court in regards to my therapy with your child, unless mandated by the court. Exceptions to confidentiality include: 1) evidence suggests physical, sexual or emotional abuse and neglect of a child, a disabled individual, or the elderly, 2) the client presents with suicidal ideation and refused to comply with safety commitments, 3) the client reports a plan to harm a specific-named individual, 4) where permitted by or required by law (i.e., insurance agreement, legal subpoena), 5) consultations with my DBT consultant and consult group, my EMDR consultant and consult group. These conversations with my consultants will take place in an area and in a manner in which they will protect your privacy. My duty to provide confidentiality will survive the death of a client unless otherwise authorized by the client prior to death.


I will maintain documentation of all consents, authorizations, notices of privacy practices, Office Policies and Procedures, trainings, and patient requests for records or amendments to records. I will document complaints received and their disposition. Client records will be kept locked in my office or in a locked file cabinet offsite. I will keep client records for seven years from the date of the last treatment session. With respect to the records of a minor, I will keep those records for at least seven years or until the patient is twenty- one years old, whichever is longer. Thereafter, I may destroy client records. When records are destroyed they will be done so in a manner that protects client privacy and confidentiality.


There may be times when I take vacation. If you feel you would like to meet with another clinician in my absence, I will talk to you about having access to one of my colleagues in the office. In the case of my death, the custodian of your records is a designated colleague in my office. Exceptions made at discretion of therapist.


If a client is in crisis and unable to reach me, please call the 24 hour Crisis Clinic Line toll free 1-866-427-4747 or TDD Line access 206-461-3219. If you have life threatening emergency, call 911 immediately or go to the nearest hospital emergency room. Please be aware, my email address is not a crisis resource, is not checked regularly, and is only to be used for scheduling or cancellations.


My fee for a 75 minute intake assessment or extended session is $250. My Fee for a 50 minute session is $165. Fees are to be paid at the beginning of the session unless discussed otherwise. I accept cash, check, or credit cards. I take exact change only, as I do not keep a cash box or safe on the office premises for change. If a client is unable to pay the service fee, I have the right to terminate therapy and refer the client to a low cost counseling center. There is a $25 fee for any returned checks. I am open to phone calls between sessions and phone calls that last more than 15 minutes will be charged at my hourly rate. Work such as writing assessments or letters on your behalf or talking to other care providers will be charged at my hourly rate. It is my policy not to become involved in clients’ legal matters (e.g. divorce, custody, immigration, etc.) If subpoenaed to testify in court regarding you and your psychological work with me, my base fee would be $425/hour and additional fees may apply. Fees are subject to change or increase at the discretion of the therapist. Exceptions made at discretion of therapist.


I have a 24 hour cancellation policy. If you are sick or otherwise unable to make it to the scheduled appointment, you must contact me at least 24 hours before the appointment. Failure to do so will result in being charged the full session rate. This fee will be due prior to the beginning of the next session. Exceptions made at discretion of therapist.


If a client chooses to contact me via cellular phone, text message, email, or fax, she/he understands complete client privacy and confidentiality will be at risk due to intercepted calls, technological hackers, or accidentally dialed fax numbers. Clients are responsible for advising me if there is not a safe phone number or address to be contacted, otherwise, I have the right to attempt contacting clients according to the information provided by the client on the registration form.


It is my philosophy that counseling and consultation is a joint effort. Your active participation is a key factor for successful outcome. My approach to therapy is primarily informed by behavioral therapy, which means I will tend to focus on the here and now, skill building, and your life in the present moment. We will jointly create a plan for treatment based on your needs and goals. At times, individuals will experience the services offered to result in emotional discomfort, changes in relationships, and temporary worsening of symptoms. These difficulties typically subside as our work together progresses. However, it is important that you share this information during sessions. Please feel invited to bring up any needs, requests, concerns, or questions at any time. Remember, you always have the right to request changes in, or to refuse, treatment at any time. Termination of Counseling Services is assumed after 4 consecutive missed sessions, and at that time, your file will be closed.


This notice describes how clinical information about you may be used and disclosed and how you can get access to this information. Please review carefully.

If you have any questions about this notice, please contact Teresa La Fleur at 425.681.1528. Or write to: Bellefield Office Park – Cedar Bldg, 1400 112th Ave. S.E. Suite 202, Bellevue, WA 98004.

This notice describes the information privacy practices followed by my employees, staff and other office personnel. Your privacy is protected by law. I serve as my own Privacy Officer.


This notice applies to the information and records I have about your health, health status, and the health care and service you receive at this office. Your health information may include information created and received by this office, may be in the form of written or electronic records or spoken words, and may include information about your health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information. I am required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.


I may use and disclose health information for the following purposes:

For Treatment: I may use health information about you to provide you with clinical treatment or services. I may disclose health information about you to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you and your health.

For Health Care Operations, consultation, and supervision: I may use and disclose health information about you in order to run my office more efficiently and to make sure that you and our other patients receive quality care. For example, I may use your health information to evaluate my performance in caring for you through consultation and supervision. I may also disclose your health information to health plans that provide you insurance coverage (should you try and seek reimbursement) and other health care providers that care for you.

Appointment Reminders: I may contact you as a reminder that you have an appointment for treatment or clinical care at this office.

Treatment Alternatives: I may tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Products and Services: I may tell you about health-related products or services that may be of interest to you.

Please notify me if you do not wish to be contacted for appointment reminders, or if you do not wish to receive communications about treatment alternatives or health-related products and services. If you advise me in writing (at the address listed at the top of this notice) that you do not wish to receive such communications, I will not use or disclose your information for these purposes.


I may use or disclose health information about you for the following purposes, subject to all applicable legal requirements and limitations:

Child Abuse: I am required to report all suspected cases of physical and/or sexual abuse or neglect of children to the Department of Human Services (DHS).

Elder Abuse: I am required to report suspected cases of elder abuse or neglect to the Senior & Disabled Services Division.

Serious Threat to Health or Safety: I may use and disclose health information about you when necessary to prevent a clear and substantial risk of harm being inflicted by you on yourself or another person. When there is a clear and substantial risk of harm to another individual I am required to warn law enforcement officials and the intended victim.

Workers' Compensation: If you file a worker's compensation claim, this constitutes authorization for me to release relevant mental health records to involved parties and officials.

Health Oversight Activities: I may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, I may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, I may also disclose health information about you in response to a subpoena.

Law Enforcement: I may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

Information Not Personally Identifiable: I may use or disclose health information about you in a way that does not personally identify you or reveal who you are.

Research: If you were to sign a consent form to participate in a research study, I might use and disclose health information about you for research projects that are subject to the approval process specified in the consent form. This does not apply to you if you have not been asked to participate in a research study.


I will not obtain, use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. If you give me Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, I will no longer obtain, use or disclose information about you for the reasons covered by your written Authorization, but I cannot take back any uses or disclosures already made with your permission.


You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy your health information, such as clinical and billing records, that we keep and use to make decisions about your care. You must submit a written request to Teresa La Fleur, MA in order to inspect and/or copy records of your health information. If you request a copy of the information, I may charge a fee for the costs of copying, mailing or other associated supplies. I may deny your request to inspect and/or copy in certain limited circumstances. If you are denied copies of or access to health information that we keep about you, you may ask that our denial be reviewed. If the law gives you a right to have our denial reviewed we will select a licensed health care professional to review your request and my denial. The person conducting the review will not be the person who denied your request, and I will comply with the outcome of the review.

Right to Amend: If you believe health information I have about you is incorrect or incomplete, you may ask me to amend the information. You have the right to request an amendment as long as the information is kept by this office.

To request an amendment, request, complete and submit a CLINICAL RECORD AMENDMENT/CORRECTION FORM to Teresa La Fleur, MA.

I may deny your request for an amendment if your request is not in writing or does not include a reason to support the request. In addition, I may deny your request if you ask me to amend information that I did not create.

Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is a list of the disclosures I made of clinical information about you for purposes other than treatment, payment, health care operations, and a limited number of special circumstances involving national security, correctional institutions and law enforcement. The list will also exclude any disclosures I have made based on your written authorization. To obtain this list, you must submit your request in writing to Teresa La Fleur, MA. It must state a time period, which may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free.

For additional lists, I may charge you for the costs of providing the list. I will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions: You have the right to request a restriction or limitation on the health information I use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information I disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. I am not required to agree to your request. If I do agree, I will comply with your request unless the information is needed to provide you emergency treatment.

Right to Request Confidential Communications: You have the right to request that I communicate with you about clinical matters in a certain way or at a certain location. For example, you can ask that I only contact you at work or by mail. I will not ask you the reason for your request. I will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.


If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with my office, contact Teresa La Fleur MA, 425.681.1528, 1400 112th Ave. S.E. Suite 202, Bellevue, WA 98004. If you request assistance filling out the complaint forms, someone will be assigned to help you. You will not be penalized for filing a complaint. If you have any questions about my privacy practices, please ask for clarification. If you require further clarification at any time, please contact me.


By signing this form below, I acknowledge I have read and understand the above therapist disclosure, consent to receive counseling services, client responsibilities and treatment contract. I have received copies of the HIPAA privacy practice guidelines. I agree to abide by the above client responsibilities and to actively participate in the counseling environment. I understand that if I withhold important critical information from my therapist, I will be interfering with my own counseling progress and I will potentially jeopardize the therapeutic process. I understand my rights as a client. I have been given the opportunity to ask questions. I understand this is a legal document and contract. I have been given a copy of this contract.

Teresa La Fleur, M.A. LMHC | | 202 (425) 681-1528

Bellefield Office Park ~ Cedar Bldg | 1400 112th Ave. S.E., Suite | Bellevue, WA 98004

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Document name: Informed Consent for Counseling Services: Treatment, Disclosures, Payment Information, & Privacy Rights
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November 25, 2017 1:07 pm PDTInformed Consent for Counseling Services: Treatment, Disclosures, Payment Information, & Privacy Rights Uploaded by Teresa LaFleur - IP