• THERAPIST DISCLOSURE STATEMENT & CLIENT INFORMED CONSENT

  • Julie Holt, MA, LMHC Julie Holt LLC – EIN 45-3194482

  • 2366 Eastlake Avenue East, Suite 417 Seattle, WA 98102 206-979-6764 julieholtcounseling.com

    You have the right to refuse any treatment you do not want and the right to choose a counselor who best suits your needs and purposes. With that in mind, the following disclosure is provided to you. Please read each section carefully and initial each page.

    I. THERAPIST DISCLOSURE TO CLIENT

    Credentials: I am a Licensed Mental Health Counselor in Washington State (#LH60406542) Education, Training, and Experience: I received a Bachelor of Arts in Psychology from the University of Washington. I completed my Master of Arts in Psychology with a Specialization in Systems Counseling from the Leadership Institute of Seattle (LIOS), a graduate college at Saybrook University in California. I completed my internship hours at Compass Health where I counseled children, adolescents, adults, and their families. I have also worked with the King County Crisis Clinic as a volunteer crisis phone worker and with Seattle Shanti (a division of Rosehedge/Multifaith Works) as a one-on-one emotional support volunteer. I began my training in the mental health field more than 20 years ago. Professional Memberships: I am a member of the American Mental Health Counselor Association (AMHCA) and the former President of the Seattle Counselors Association (SCA I am also a member of RPPS a relational psychoanalytic psychotherapy training society in Seattle. Services Provided: I provide psychotherapy for individuals (adults aged 18 and older), couples, and families. I provide consultation to other mental health professionals on topics relating to anxiety, depression, and relationship/social issues.

    Confidentiality: Your participation in therapy, the content of our sessions, and any information you

    • provide to me is protected by legal confidentiality. Some exceptions to confidentiality are the following situations in which I may choose to, or be required to, disclose this information:
    • If you give me written consent to have the information released to another party;
    • In the case of your death or disability I may disclose information to your personal representative;
    • If you waive confidentiality by bringing legal action against me;
    • In response to a valid subpoena from a court or from the secretary of the Washington State Department of Health for records related to a complaint, report, or investigation;
    • If I reasonably believe that disclosure of confidential information will avoid or minimize an imminent danger to your health or safety or the health or safety of any other person;
    • If, without prior written agreement, no payment for services has been received after 90 days, the account name and amount may be submitted to a collection agency.

    As a mandated reporter, I am required by law to disclose certain confidential information including suspected abuse or neglect of children under RCW 26.44, suspected abuse or neglect of vulnerable adults under RCW 74.34, or as otherwise required in proceedings under RCW 71.05.

  • Health Care Coordination: It is important to make sure that the problems you present are not related

    to a physical health difficulty. Since I am not a medical provider, I cannot determine if you have physical conditions that might be related to your health and our work. Therefore, it is advised that you get a physical examination from a physician as soon as possible. It would be best to tell your medical provider that you will be working with me so we might begin to coordinate your health care. With your written authorization, I may obtain your medical records so I have a better understanding of your overall health.

    Risks and Benefits: During the course of therapy, you might notice changes in your symptoms,

    problems, and functioning. Since we will be exploring challenging territory in your life, you might experience greater difficulty throughout our work. This is absolutely normal. Counseling is intended to alleviate problems, but sometimes as you get to the root of some issues, you may feel them even more acutely than in the past.

    First Session: Please complete the following paperwork before your first in-person session: New

    Client Form, Disclosure Statement, and Notice of Privacy Practices. During the first session, we can review your paperwork, discuss the reasons why you are seeking counseling, and talk about your goals. Additionally, I can answer any questions you might have about therapy. We will schedule our next appointment at the end of each session, though generally we will establish an ongoing time reserved for you weekly.

    Appointments: Please notify me via phone, at (206) 979-6764, or by email

    Julie@julieholtcounseling.com at least 24 hours in advance (48 hours is requested) if you have any schedule conflicts or emergencies which would require you to cancel our appointment. Please note that text messages cannot be used for cancellation notices. Likewise, I will notify you via phone or email if I should need to cancel our appointment. Please pay attention to any illness symptoms you may have that may interfere with your ability to make our appointment. When you arrive for an appointment, please make yourself comfortable in the suite’s waiting room. Our sessions will be about 45-50 minutes long (standard for therapy appointments), and we will need to end on time. I charge the full session fee for any sessions that are shortened due to your late arrival or early departure. I cannot accommodate making up for lost session time unless it is due to my error. Please note that you are responsible for the full session fee if you miss an appointment without 24 hours notice of any cancellations. You will not be charged if I cancel our appointment or in the case of extreme emergencies. Waking up sick on the day of our appointment when no other symptoms were there the day before would qualify for this type of emergency. Please be prepared to pay the full session fee from your appointment that was either missed or cancelled late (not within 48 hours) when you attend your next scheduled appointment. Also, please note that most insurance companies will not reimburse in any case for a late cancelled or missed session.

    Fee for Services: My standard fee is $160.00 per 45-50 minute session. This is the same fee charged for

    any missed or late canceled appointments. Additional fees might include: preparation of requested documents, or copying and sending records. I will discuss any fees with you at the time of a request. Please inform me of any change in your financial situation that impacts your ability to pay for services. I do sometimes raise my fee. I will give you notice of this usually a month in advance. At this point, I tend to raise my fee at the beginning of the calendar year, but I do not raise it every year. My intention is to keep my fee in line with the Seattle area such that you will find similar rates throughout the Seattle Metro area for similar services.

  • Payment for Services: I accept cash or personal check payments made payable to Julie Holt.

    Payments are due directly to me at the time of service (please have checks complete at the beginning of each session) unless we make arrangements otherwise. If paying by cash or check is a barrier, I can arrange to have you pay by debit/credit card using Paypal Merchant (though they charge roughly a 3% fee on top of this If payments are not made at the time of service or in a timely manner that we have agreed upon, then I may notify debt collectors. I reserve the right to charge a $30 fee for any returned checks.

    Insurance: Though I do not bill insurance, I can provide you with a receipt, called a “superbill”, that

    you can submit to your insurance company for reimbursement. This is a relatively easy process and I am happy to assist you in finding the appropriate forms for your carrier, but I will not directly bill or make submissions for reimbursement to your health insurance provider. As I am a Licensed Mental Health Counselor, it is possible that I will be covered by your insurance carrier as an out-of-network provider. That generally means that they may reimburse you for 50%-100% of my fee. You are responsible for the remainder. Check with your carrier, though, for your specific plan details and specifically ask them if they will cover your sessions with me. There are benefits and drawbacks to using insurance and we can discuss these at our first session.

    : You may call me anytime and leave a message on my voicemail, and I will get back to you as soon as I can. I generally retrieve my messages daily, and

    Emergency, Urgent, or Other Contacts

    whenever possible, I will get back to you within one business day. At times, however, it may be significantly longer. If you need to cancel or reschedule an appointment, please do so via phone at least 24-48 hours in advance. This is to ensure my ability to accommodate other clients and to maintain my work flow. Please note that if there is information to communicate to me, it is necessary that you do it within our session time so that we have the opportunity to process what is emerging. For this reason, I usually do not return email messages once we have begun our counseling relationship. Please also remember that anything you send over email can not be guaranteed as confidential. If you have a physically or psychologically life-threatening emergency, please immediately call 911, and/or the King County Crisis Clinic at (206) 461-3222. The Crisis Clinic has 24-hour availability to offer crisis counseling, community resources, and emergency assistance. Do not use email to communicate emergent or crisis information. I am not able to provide on-call crisis or emergency services. If I will be out of town or otherwise unavailable for an extended period of time (generally if longer than two weeks), I will provide you with alternate contact information should you need support during my absence. This is usually in the form of trusted associates of mine licensed in my field.

  • : I engage in regular ongoing consultations with Karen Weisbard, PsyD, and Doug Hansen, MSW. Their contact information can be found easily on the internet.

    My Supervision and Consultation

    Additionally, I am part of several regularly held consultation groups in which I deepen my understanding of how I can provide the highest level of service to you as a holistic healing practitioner. I also am in mentorship under a shamanistic practitioner – I will provide further details for you about this if you wish. I may disclose information about you in consultation with colleagues, in which case I will limit the information I disclose to the minimum amount necessary.

    Access to Records: I have an agreement with Karen Weisbard to access my client files in order to

    make appropriate notification and referrals in case I am temporarily or permanently incapacitated. If you do not consent to Karen Weisbardaccessing your file in case of my incapacity, please let me know so that I may make alternative arrangements.

  • : It is my intention to maintain a relatively comfortable, safe, and professional environment where I consider your best interests my priority (safe

    Therapy Relationship and Professional Boundaries

    enough to take risks Because I have the utmost respect for you and our therapeutic relationship, professional boundaries are essential so that no harm or damage is done. I uphold the following practices regarding professional relationship boundaries:

    1) I will not, at any time, have a social relationship with you outside of my office, even after we have ended our therapeutic relationship. This is a legal boundary, not one of not caring. 2) Because my business does have an internet presence (listings on Yelp, Facebook, etc), it is possible for you to place unsolicited reviews on those sites of me and my business if you wish. It is very important to your treatment that you communicate your intent to do so prior to actually doing it. This is to keep communication flowing between us. In other words, if you have feedback for me (positive, negative, or ambivalent) it is best for us to discuss them in person as they are likely very important for your treatment. I always appreciate word of mouth referrals to your friends and associates. 3) I will not, at any time, have physical or sexual contact with you. This excludes handshakes and the like, but only when or if you initiate. None of these are expected from you, though. 4) I will not, at any time, accept any gifts from you. 5) If I were to see you in public at any time, I will not initiate any contact or familiarity with you. Again, if you initiate I will respond in kind, but no further than you offer. 6) I will not, at any time, have a relationship with you beyond my range of psychotherapy, counseling, and referrals, and the collection of fees for these professional services. Additionally, I will not provide any services beyond my expertise, including legal or medical advisement. 7) I will only provide appropriate referrals to other health professionals with your consent. I do not make referrals to lawyers, accountants, financial planners, credit counselors, or other non healthcare related individuals and agencies. I do not accept payments for giving referrals. 8) I will uphold confidentiality standards pertaining to Federal and State of Washington law during the course of therapy and thereafter. By law, our sessions are considered “privileged.” Neither your death nor mine terminates your confidentiality rights.

    Telehealth: If it is therapeutically appropriate, I may make use of technology assisted telehealth tools

    • such as telephone communications and internet enabled video and/or audio services as an adjunct to our in-person work together. It is important that you understand the benefits and limitations of such services.
    • Since in-person interaction is generally more clinically effective than telehealth, preference will be given for in-person services unless individual or environmental factors indicate telehealth as a preferable alternative.
    • Telehealth services may only be initiated after completion of initial in-person sessions sufficient to facilitate an adequate preliminary assessment and diagnosis. This generally will require at least one full clinal session. This requirement may be waived under extraordinary circumstances.
    • Telehealth services may improve your access to counseling, may reduce your costs associated with counseling, and may support more effective use of in-person counseling.
    • If you are located outside of the State of Washington, the counseling services I am allowed to provide to you may be limited or prohibited. If you are located outside of the State of Washington, we will discuss what services I may be able to provide to you.
    • Telehealth services are not appropriate for all clients and all situations. If you or I determine that telehealth services are not appropriate for you, I will assist you in obtaining appropriate alternative services.

    • Successful use of telehealth services requires a reasonable level of access to computer hardware and software. If you do not have access to such resources, we can discuss available alternatives.
    • At times it may become necessary for me to allow access to my computer hardware and software for purposes of system maintenance, repair, upgrades, or other similar purposes. In such cases, I will make reasonable efforts to protect your confidential information.
    • Telehealth services are often not reimbursed by insurance. In such cases, payment for telehealth services remains your sole responsibility.
    • In case of hardware, software or other system failure, you may reach me by phone to coordinate our continued work together.

    • At the beginning of each session I will ask you to provide me with the following information:
    • Your physical location and address;
    • A phone number I can use to contact you in case of technology failure or other loss of internet connection during our telehealth session;
    • An email address I can use to contact you as an alternative if we cannot connect via phone.

    • At the initiation of our therapeutic relationship I will ask you to provide me to the following contact information if you and I are in different geographic locations:
    • Your local hospital emergency room phone number;
    • Your local crisis line phone number.
    • The phone number of a local clinician who can provide you with appropriate alterative services in case you or I determine that my telehealth services are no longer appropriate for you.

    : You have the freedom to make decisions as you please. You may engage in therapy for as long as you like. You may, at any time, change your goals for

    Therapeutic Work, Duration, and Termination

    therapy, and/or you may choose to end our relationship, no matter where you are in the process of goal achievement. I respect and promote your right to make your own decisions. I believe doing so is part of the healing process in therapy. When or if you would like to end therapy, I do ask that we first discuss this in person. This is due to the fact that sometimes when old wounds are reopened a natural human tendency can be to flee. Part of our therapeutic relationship is safely and comfortably looking at these wounds to find ways to heal them. The very notion that you might want to leave abruptly might be an indication that we are making great progress!

    If, without having made prior arrangements, I have not heard from you in 30 days I will assume that you would like me to terminate our current episode of care and close your active clinical file. In such cases, we may re-open the file and initiate a new episode of care once we meet in person.

    Complaints: If you have a complaint or inquiry about my professional service that cannot be resolved

    with me directly, please contact the Washington State Department of Health. Complaints or inquiries can be sent to: The Department of Health, Health Professions Quality and Assurance Division, P.O. Box 47869, Olympia, WA 98504-7869. A copy of the acts of unprofessional conduct can be found in RCW 18.130.180.

  • Confirmation of Informed Consent

  • Julie Holt, MA LMHC Julie Holt, LLC

  • 2366 Eastlake Avenue East, Suite 417 Seattle, WA 98102 206-979-6764

    Please initial each statement, and sign below:

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  • This form will be retained in the mental health record.

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