disclosure
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disclosureworkingdocjan19.docxDNA Counseling - Denise Arnold Counseling, LLC
Informed Consent and Confidentiality Statement
Denise Arnold, Licensed Mental Health Counselor (LMHC)
520 Lilly Rd NE, Bldg. 1 Olympia, WA 98506 253-740-9006 [email protected] License # 00009987
Welcome
Welcome, I am glad you are here. I realize that seeking counseling can be a brave step.
Counseling is a process of sharing one’s story and exploring patterns, strengths, and relationships in the process of meeting a goal or goals. As your counselor, it is my hope to help you achieve successful outcomes.
Credentials and Experience
Ph D, Gonzaga University, Spokane WA 2001
Master of Divinity, California Lutheran University, Thousand Oaks, CA 2015
Master of Human Relations, University of Oklahoma, Norman, OK 1996
Bachelor of Arts (BA) Communication University of Washington, Seattle, WA 1987
Licensed Mental Health Counselor in the State of Washington 2006- Present National Board Certified Counselor (NBCC) 2006- 2022
Full Professor and Department Chair Social Services and Mental Health, Pierce College 2004 – Present
What to expect – the course of treatment
The counseling process can be challenging and involves hard work. However, the goal is to bring about positive change. It is my desire to make the process as comfortable and welcoming as possible. During our initial counseling/meeting, we will address your concerns and explore your story. We will then agree upon goals and work through obstacles until you feel you have reached your desired outcomes.
Therapeutic Orientation – Treatment Philosophy
I use a variety of therapy techniques. I try to match the therapeutic approach with the need expressed. Possible techniques include: Cognitive Behavior Therapy, Talk Therapy, Humanistic Therapy, Family Systems Therapy and other recognized techniques. We begin with your story as you talk freely. We will then identify patterns and relationships. We will search for strengths and work to use your strengths to accomplish your goals.
Should you desire to discuss spiritual matters, I am open and willing to embrace spiritual treatment plans in accordance to your belief system. I am an ordained pastor in the Evangelical Lutheran Church of America (ELCA) which is a reconciling in Christ ministry welcoming the LGBTQ community without judgment.
To learn more about the types of counseling mentioned above, please visit these sites:
Cognitive-behavioral therapy. National Association of Cognitive-Behavioral Therapists. http://www.nacbt.org/whatiscbt.htm. Accessed Jan. 10, 2016.
Reference Sites continued:
Talking Therapies Explained (n.d.). NHS. Retrieved from http://www.nhs.uk/Conditions/stress-anxiety- depression/Pages/Types-of-therapy.aspx#counselling
Understanding Psychotherapy and how it Works (n.d). American Psychological Association. Retrieved from http://www.apa.org/helpcenter/understanding - psychotherapy.aspx
Dual Relationships -relationships outside of counseling
I am very conscientious about your confidentiality in counseling. If we should cross paths outside of the counseling office, I will not acknowledge you. This is to protect your privacy, as others may know I am a counselor and could assume you are in counseling should we have contact. Outside relationships are not professional and can impair the therapeutic process.
Limits of Confidentiality
There are limits to what is held confidentially in counseling. According to RCW 18.19.180 the following information may be disclosed (shared with others).
(1) Information with the written consent of the client or, in the case of death or disability, the client’s personal representative, other person authorized to sue, or the beneficiary of an insurance policy on the person's life, health, or physical condition;
(2) A counselor registered under this chapter is not required to treat as confidential a communication that reveals the contemplation or commission of a crime or harmful act;
(3) If the client is a minor, and the information acquired by the counselor indicates that the minor was the victim or subject of a crime, the counselor may testify fully upon any examination, trial, or other proceeding in which the commission of the crime is the subject of the inquiry;
(4) If the client waives the privilege of confidentiality by bringing charges against the counselor; (5) In response to a subpoena from a court of law or the secretary- the secretary may subpoena only records related to a complaint against the counselor or report under chapter 18.130 RCW; or (6) As required under chapter 26.44 RCW (all suspected child abuse must be reported within 48 hours) and any suspected abuse of vulnerable adults (RCW 74.34) or as required in proceedings under RCW 71.05.
I seek ongoing consultation from colleagues to provide the best services possible for my clients.
I reveal only the minimum of information required and no personal identifying information. This is done to seek the best possible guidance for you.
Confidentiality with minors:
In Washington State, the law protects confidentiality of minors 13 years of age and older. Adolescents 13 and older are able to decide what information is released to others, and to whom, including parents and legal guardians.
Fees for Service
Regular sessions (55 minutes) $125.00. If you need to cancel a scheduled appointment, you must give 24-hour notice, or you will be charged $125 for the missed appointment. Please be on time for your sessions. Methods of payment accepted: cash and credit card.
I may use and disclose medical information about a client to obtain payment for services received by the client. For example, a bill may be sent to you or a third-party payer (such as insurance). Fees will be paid prior to each session beginning. No refunds.
Clients are not liable for any fees or charges for services rendered prior to the receipt of this disclosure statement. The initial fee for the first session is $175. I offer a sliding scale for low income individuals who meet the qualifications and have no insurance available.
Insurance
If you choose to use insurance to pay for services (third-party payers), I will be required to provide them with type of services 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 this information shared, then you will be required to pay for services prior to each session.
Contact Information
You may reach me by telephone during normal business hours. I will also respond to text messages during normal business hours.
If you need emergency services, please call 911.
The Thurston County Crisis Line phone number is (253) 586-2800. http://www.crisis - clinic.org/pdf/CommunityServicesListThurston.pdf The National Suicide Hotline is 800-784-2433.
I can direct you to a list of other counselors in the area if your needs are beyond my scope, or you request another counselor.
I discourage any use of social media for contact as it cannot assure confidentiality. I will not reply to you on Facebook, Twitter, or other forms of social media.
Legal Issues
I will not serve as an expert witness and will not participate in any legal litigation cases.
Electronic Record Disclosure
I keep and store records for each client in a record-keeping system produced and maintained by McGuire Billing & Clerical, LLC, and a “cloud based” data system, meaning the records are stored on servers that are connected to the Internet. Here are the ways in which the security of these records are maintained:
I have entered into a HIPAA Business Associates Agreement with McGuire Billing & Clerical, LLC using Office Ally. Because of this agreement, is obligated by federal law to protect these records from unauthorized use or disclosure. The computers on which these records are stored are kept in secure locations, where various physical security measures are used to maintain the protection of the computers from physical access by unauthorized persons.
Your Rights
You have the right choose counselors who best suit your needs and purposes. You have a right to refuse treatment. Counselors practicing counseling for a fee we must be credentialed through the department of health for the protection of the public health and safety. Credentialing of an individual with the department of health does not include a recognition of any practice standards, nor necessarily imply the effectiveness of any treatment. The purpose of the Counselor Credentialing Act, chapter 18.19 RCW; is to provide protection for public health and safety; and empower the citizens of the state of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct.
A copy of unprofessional conduct in RCW 18.130.190 is available upon request. You can contact the Washington State Department of Health at: Health Systems Quality Assurance (HSQA), Complaint Intake, P.O. Box 47857, Olympia, WA 98504, phone number: 360-2364700, or email: [email protected].
Your signature below indicates that you have read the information in this disclosure statement and understand and agree to the terms herein and have received a copy of your HIPAA, the Washington State Notice of Rights and Privacy Practices, and have had an opportunity to ask questions.
Print Client Name(s)___________________________________________ Date____________
Signature: ___________________________________________________Date____________
Print Client Name(s)___________________________________________ Date____________
Signature: ___________________________________________________Date____________
Print Guardian Name (if client is a minor): _________________________________________
Signature: ____________________________________________________Date____________
Print Counselor Name : Denise Arnold
Counselor Signature :___________________________________________Date_____________
My initials show that I have read, understand, and agree to everything on this page ______
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