Disclosure Statement—Policy & Procedures
I am pleased that you have selected me as your therapist and I look forward to working with you. This document is designed to inform you of my background and professional standing and to ensure that you understand our professional relationship. Treatment Philosophy I believe that therapy is one of many tools in the recovery and healing process. Because you have decided to embark on this journey, I trust that you are committed to the process of therapy and the active participation in this process. As your therapist, my relationship with you is a collaborative, respectful and professional one. My role is to guide and help you uncover the truth about yourself and empower you as you progress toward your true potential — your authentic Self. I do this through the meaningful connection of spirit, mind and body. My theoretical beliefs are based primarily on concepts EMDR (Eye Movement Desensitization & Reprocessing) Therapy, Ego-State Therapy & Person-Centered Therapy. My approach to therapy varies, understanding that each individual embraces self-understanding, healing, and change in different ways. Some of these ways include: EMDR, Guided Visualization & Meditation, Resource Development, Imaginal Nurturing & Ego State Therapy. The length of therapy varies from person to person depending on experience and goals. When you’ve reached your therapy goals, my usual practice is to start decreasing the frequency of follow-up sessions until it seems therapeutically appropriate to conclude therapy altogether. I do not offer any court-related services, including live testimony and written. EDUCATION & TRAINING I hold a Master of Education degree in Counseling Psychology from Washington State University and am a Licensed Mental Health Counselor in the state of Washington (License # LH00011204). I am also certified in EMDR Therapy (Eye Movement Desensitization & Reprocessing: www.emdr.com), a method which works well with folks who are suffering from past trauma & neglect, current anxieties, low self-esteem and phobias. I have experience working with survivors of sexual assault & childhood abuse, childhood neglect, combat trauma, first responder trauma, tragic loss, traumatic grief, religion/cult abuse, medical abuse and folks suffering from mood disorders, and the everyday challenges of life. RISKS & BENEFITS Counseling can have benefits and risks. Since it often involves addressing unpleasant aspects of your life, you may experience uncomfortable feelings, such as sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, counseling has also been shown to have many benefits. It often leads to better relationships, it can provide solutions to specific problems, and there is often a significant reduction in feelings of emotional distress. Feeling uncomfortable is usually temporary as you deepen your capacity to be fully present to your experience and improve your self-care. You are encouraged to ask questions or talk to me about any concerns you have about our work together. PAYMENT, RATES, BILLING & INSURANCE Responsibility for effective therapy belongs to both the client and therapist. As your therapist I am responsible for offering you counseling that reflects quality, ethical standards of this profession and a commitment to the therapeutic relationship. As a client your responsibilities include arriving for your appointments on time and as scheduled, giving an honest effort during your therapy and accepting financial responsibility for your counseling charges. Co-pay, deductible or regular payment is expected at the beginning of each session. If you are using your insurance benefit, you are responsible for paying any co-pays, co- insurance and/or deductibles. If you are using an insurance benefit for which I am considered an “Out of Network” provider, you are responsible for paying the difference of what the insurance company will not reimburse. I accept debit/credit cards, checks, money orders, and cash. For those who are covered by two insurance providers, I will bill your primary, but not your secondary insurance company. If you need reimbursement from your secondary insurance, you will need to submit those claims to that company. I can provide you the appropriate paperwork to submit your own claims.

FEES SCHEDULE

First Appointment (Intake & Assessment):   $160.00 Individual Therapy Appointments:   $150.00/session hour Phone Calls Longer than 15 Minutes:   $40.00/15 min. When I periodically increase my rates you will be notified and your current rate will remain in effect for 30 days. If you do not have, or you choose not to use insurance, you may pre-pay for a package of sessions at a slightly discounted rate. Please inquire about Value Package rates if this interests you. Occasionally a client will have an outstanding balance on their account (usually due to missed appointments and/or outstanding insurance deductibles). A credit card # is required for any outstanding balances. You will receive an email invoice notifying you of your outstanding balance. You have 30 days to pay the outstanding balance. If payment is not received and payment arrangements have not been made, Sacred Healing Place will charge your credit card (on file) for the outstanding balance. Credit card processing is done through SquareUp.com. COMMUNICATION Use of Email and/or Text Messaging: These forms of communication have become convenient in our day & age. Simply by their nature, electronic forms of communication are not completely confidential, even though I am the only one who reads and responds to emails and text messages. Please note that I use email and text messaging only for the purposes of scheduling or re- scheduling appointments or answering simple questions about billing, co-pays, hours of operation, etc. Therapy-type questions or comments (such as “do you think…?” or “should I do…?” etc.) should be addressed during the therapy session as they can be easily misinterpreted in the written form. Phone Calls: I do not charge for brief (15 min or less) phone conversations, when they are possible. For longer calls, I charge a pro-rated rate based on my current hourly rate. If your matter is urgent, please call the 24 hr. Pierce County Crisis Line at 1-800-576-7764. I typically take vacation 2-3 weeks throughout the year. If you believe you will require a therapist that has 24-hour support, please discuss this with me as soon as possible so that I may help you find someone who can meet that need. WAITING ROOM, SESSIONS, PARKING Sessions: Most therapy sessions are 55-60 minutes long. However, I also offer Intensive Healing Sessions at *3-7 hours per session. This is a great option for folks who cannot commit to weekly appointments and/or who desire intense, deep work without the interruption of “daily life.” *(if using insurance, only the first hour is covered). Children: Children under the age of 11 are not permitted to wait in the waiting room alone and children of any age are not permitted to attend your counseling session with you. Parking: Street parking is allowed on N. K Street and the surrounding neighborhood. Please be mindful of not blocking driveways or curb ramps. And please secure your vehicle and belongings. Sacred Healing Place is not responsible for any parking-related tickets issued by the City of Tacoma or any vehicle-related vandalism and/or theft. SCHEDULING & CANCELLING Cancellation of your appointment at least 24 hours in advance (or less if an emergency or illness) results in no charge. Getting called into or staying late for work is not considered an emergency. Less than a 24 hour notice results in a charge at my full fee rate as your time slot is reserved for you only and insurance companies will not reimburse for no-shows and cancellations. If you reach my voicemail when cancelling an appointment, please leave a message; I will confirm by returning your call and re- scheduling your next appointment. Thank you for your consideration. You may also text me at 253-230-5754 to cancel & reschedule your appointment. I do not use a reminder system for appointments. Once we schedule your appointment, you are responsible for showing up to your appointment on time without any reminders from Sacred Healing Place. If you show up 15+ minutes late (and are using insurance), you will be charged the difference of what your insurance company will reimburse. If it’s 15+ minutes past your appointment time and I haven’t heard from you, I will assume this to be a ‘no-show’ and may leave the office. Cancellation fee will apply. YOUR LEGAL RIGHTS NOTICE OF INFORMATION PRACTICES AND RELEASE OF INFORMATION: Sacred Healing Place will keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it at your request.
PRIVACY POLICY: In accordance with federal, state, and local laws, information about you will be protected from unauthorized disclosure. Sacred Healing Place will disclose health care information without your authorization if the disclosure is to federal, state, or local public health authorities, to the extent we are required by law to report health care information; when needed to determine compliance with state or federal licensure, certification or registration rules or laws; or when needed to protect the public health; and to federal, state, or local law enforcement authorities to the extent required by law.
CLIENT RIGHTS: 1. You have the right to be treated with respect and dignity; to develop and understand available treatment options and alternatives and to participate in decisions for a plan of care and services which meet your unique needs provided in a barrier-free location which is accessible to you; 2. You have the right to receive tailored care which does not discriminate against you and is sensitive to your gender, race, national origin, language, age, any disability, and sexual orientation; to be free from sexual exploitation or harassment; 3. You have the right to review your clinical record and be given opportunity to make amendments or corrections; to have all personal information and records obtained, compiled, and maintained in the course of receiving services protected and kept confidential. 4. You have the right to no charge for the first 15 minutes of service if we decide not to continue a therapeutic relationship. 5. You have the right to refuse treatment, and to determine the frequency and duration of our work together. Please mention that you anticipate ending your therapy so that we may create a support plan for you. 6. In addition to this document, you received my Notice of Privacy Practices, which described how I might use and disclose your health information. Examples of when I may disclose information about you is: — To report suspected abuse of a child, a developmentally disabled person, or a vulnerable adult; to interrupt potential suicidal behavior; to intervene against threatened harm to another, which — may include knowledge that a patient is HIV positive but a patient is unwilling to inform others will whom he/she is intimately involved; and if required by court order or other compulsory process. — If you sign a written authorization or me to release information to another person or agency, such as your physician. — If you file a complaint with the Department of Health, the minimally necessary disclosures will be made to present the DOH with information. 7. If you are being seen with another person present, I can make a request that each person respect the other’s right to privacy, but I cannot guarantee the other person’s actions will honor this request. 8. To enhance my clinical knowledge, I regularly consult with professional peers. If I discuss aspects of our work together, your name and other personal identifying information will not be shared. 9. Most insurance companies require a clinical diagnosis, assessment, treatment plan, and summary. I cannot guarantee confidentiality as this information can become part of an EAP record, insurance record, and the Medical Information Board. You have the right to obtain services without submitting a claim for reimbursement to your insurance if you choose to do so. You may contact the State Department of Health Licensing Dept., Counselor Programs, PO Box 47869 Olympia WA 98504-7869 360.236.4902. I have read and understand the procedures and policies of this counselor. By signing this form, I am also consenting to psychotherapy treatment from Lisha Song at Sacred Healing Place, Inc. A copy of this form will be given to you and is always available at www.SacredHealingPlaceTacoma.com.