Disclosure form

Freida Fenn, MA, LMFT, CMHS

1520 Jefferson St.

Port Townsend, WA 98368

Office and Messages: 360-390-8337 * FAX 360-447-6030

Therapy Disclosure Statement

Hello and Welcome…

I provide the following information to explain the therapeutic process and let you know about your rights and responsibilities as a client. (The State of Washington places certain limitations on those rights, of which I will inform you, below.) Please read the following explanation of how I work and feel free to ask me questions.

Treatment Philosophy

I view therapy as a collaborative process between client and therapist. I work with individuals, couples and families. It is my desire to provide a safe and caring place to assist you with your challenges and issues. Together we will create a treatment plan to address your specific concerns. My work is to support the growth and change process as defined by you. No specific results are guaranteed, rather the healing and changes are yours, the client’s, to choose and make. We work together towards your treatment goals.

Therapy can bring up feelings of frustration, anger, joy, relief, sadness, anxiety, despair and hope. Clients should not be surprised when layers of feeling are stirred. These experiences are generally temporary and are part of the growth and change process. Therapy provides a safe place to explore these feelings and move towards healing and change. Sometimes people find themselves struggling with unexpected and intense reactions to the therapeutic process.
I want to hear your story. I ask questions. I gently challenge assumptions and invite clients to consider new possibilities. I often suggest small homework assignments between sessions. I might recommend readings that I think relevant to your presenting problem. I find that the more engaged my clients are, between sessions, the more you get from your sessions. I might suggest a guided self-inventory of your lifestyle: exercise, diet and other issues of self-care.

My theoretical basis for treatment is rooted in Attachment Theory. I use Cognitive-Behavioral Therapy (CBT), Trauma Focused Cognitive Behavioral Therapy (TF-CBT), Mindfulness techniques, Emotionally Focused Couple’s Therapy (EFCT), Emotionally Focused Family Therapy (EFFT) and Family Systems work.

I take a holistic approach, attending to your issues of mind, body and spirit. I may suggest you seek evaluation and/or treatment from a physician, naturopath, ARNP or psychiatrist. I might then request you sign a release form (ROI) so that I may consult with your other providers. It is my goal to see the world from your perspective and to respect your value system as we work in tandem on the issues you bring into therapy. It is your right to decline any suggestion I make.

Scope of Practice

My training enables me to work with Couples, Marital Partners, Families wanting to improve communication and parenting, people experiencing Anxiety, Depression, Grief and Loss, Trauma, Adoption, Foster Parenting, as well as behavior issues in teens and children.
I also provide Divorce Coaching and Co-Parent Coaching. I am a WA State Child Mental Health Specialist and as such work on Collaborative Divorce teams in Jefferson and Kitsap Counties. As we work together, if it becomes clear that an issue is outside my scope of practice, I will provide referrals to professionals who work in the field that matches your needs.

Voluntary Participation

The most significant change and transformation can only occur when clients engage in therapy of their own free will. Every individual, member of a family or couple needs to choose to engage in the therapeutic process. I exert no pressure to do so. I do also see some court-ordered clients under 18. I work with youth to gain their trust and build a relationship, at the behest of the courts or their parents/guardians.

My Education, Training and Experience

I am a graduate of Antioch University, Seattle, with an MA in Clinical Psychology. I am Licensed Marriage and Family Therapist (LMFT) with the State of Washington, #LF 60256546. I hold a BA in Religion and English from Pacific Lutheran University, Tacoma, Washington.

I am a Clinical Member of the American Association of Marriage and Family Therapists and adhere to their ethical guidelines in my practice. These can be viewed at:
http://www.aamft.org/resources/LRMPlan/Ethics/index.asp.

Confidentiality and Privilege

In order to provide the best possible service to you, I participate in professional consultation with other therapists. When I participate in consultation, I do not disclose a client’s name or specific information that would lead to identifying you. In clinical supervision sessions, I will protect your identity to the best of my availability.

I keep records of the services I provide for you for the legally require 10 years. You may ask to see and copy those records, or request I correct or amend them. I do not release information about you to any other party unless you request this in writing (a Release of Information document) or the disclosure is required by law or a judge’s Court Order.

At this time, I provide services via private pay and a number of insurance companies. If I do not take your insurance, I gladly provide paperwork (called a Superbill) for you to submit a claim to your insurance, for reimbursement for my services.
AN IMPORTANT NOTE TO MINORS AND THEIR PARENTS: It is my goal to encourage and facilitate safe, effective communication between parents and youth. I keep conversations in therapy with minors confidential, even when information disclosed would be of concern to the parents. I encourage teen clients to disclose to their parents, in a family session, when they are ready and willing. However, minors need to be aware that I must inform parents if anything is disclosed that indicates significant danger to the minor, or potential harm to themselves or another person.

I seek to protect the privacy of all my clients. However,

Please take note of the following important exceptions to confidentiality:

If you have signed a written consent for a Release of Information (ROI) to another party, I will follow your request and release the specific information you authorize. When counseling couples or families, each individual must sign an ROI release before information will be shared.
If you confide that you plan to commit a serious crime, harmful act, or have engaged in sexual or physical abuse or neglect of a child or dependent adult, I am required by Washington State law to report this to the authorities.
If you disclose past or current neglect or abuse of a child or dependent adult, or I strongly suspect such has or is occurring, I am required by Washington State law to notify the authorities. I am also legally required to warn a potential victim of serious harm a client discloses they intend to inflict on someone else.
If you are under 18 and are the victim of a crime which includes neglect, physical abuse or sexual abuse, I will report this to the authorities.
If you bring charges against your counselor, information will be released during said proceedings.
If a Court orders release of your records, or a subpoena is issued by the Court, an attorney or law enforcement officials, I will disclose information within the requirements and limits of the law.

Therapist Availability

I am available for additional sessions, as my schedule allows, by appointment upon client request. I also give 10-minute phone calls between sessions, at no charge, to do a check-in when the client feels the need, or I want to follow-up after an intense session. I am not on 24-hour call. I return phone messages during office hours on weekdays. I encourage clients to call Discovery Behavioral Health Crisis line if you feel in urgent need of assistance at 360-385-0321, after hours and on weekends. If you, or another, is in immediate danger, call 911.

If you wish, when I am out of town, I can leave the name, phone number and credentials of a colleague who agrees to see my clients in my absence if a minor crisis arises. This is a reciprocal agreement, which I provide to the other therapist and her clients. Confidentiality is maintained.

Social Networking, Emailing, Texting

I do not maintain electronic social network relationships with current or former clients. I may use email or texting to help set up and remind you of appointments, with your express written consent (ROI). No private content will be sent via email or text. Email is not a secure form of information, unless both parties use a secure server. Confidentiality on texting can never be assured.

Fees for Service and Cancellation Policy

MY FEES: The fee for an intake assessment session is $150 for a 75 minute session. The fee for individual adult sessions is $120 per individual 60-minute session, $120 for couples, children or families. Fees will be adjusted, pro-rated, for longer sessions. Telephone sessions 15 minutes or longer are $25 per 15 minutes. I occasionally do Skype sessions with established clients. Payment is due at each session, payable by cash, credit card or local check for full amounts or co-pays. If a check bounces, an insufficient funds fee of $50 will be added and I will no longer accept future payments by check.

I have a sliding scale for those whose income falls below the federal poverty level for their household income. I take a limited number of sliding scale clients at any given time. It is my goal to provide services to people of all income levels while maintaining my practice and livelihood in a sustainable fashion.

Sessions are 60 minutes in length. If you are late, you will be charged for the full time. Please arrive so as to begin promptly at our appointed time. If cancellation is necessary, please call as soon as possible. If I do not receive a full 24-hours notice of cancellation, you will be charged $50 the first no show, $120 thereafter for no shows (unless ill). Payment will be due at the beginning of the following session.

Quality of Service

Washington State requires the following disclosure: “Counselors practicing counseling for a fee must be registered or certified with the Dept. of Licensing for the protection of the public health and safety. Registration of an individual with the Dept. does not include recognition of any public standards, nor necessarily implies the effectiveness of any treatment.”

If you feel I have done something unethical or unprofessional in our counseling sessions, please discuss them with me so we can try to resolve your concerns. If you feel we have not and cannot resolve a complaint, you may take the issue to the Dept. of Licensing, PO Box 9012, Olympia, WA 98504. You may also contact them via their website at hsqa.csc@doh.wa.gov or phone the Health Systems Quality Assurance Call Center: 360-236-4700.

“I have been provided a copy of the above information. I have read it. I have had any questions answered and understand this legally required Disclosure Statement. I consent to counseling under the terms described above.”

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Client Signature, or (Date) Client Signature (Date)

Or Parent/Guardian (for child age12 or less) Or Parent/Guardian (for child age 12 or less)

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PRINT Client’s Name/Parent or Guardian PRINT Client’s Name/ Parent or Guardian

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Address Address

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Phone Numbers and available times Phone numbers and available times

Date of Birth_______________________ Date of Birth_______________________

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Counselor’s Signature (Date)