DISCLOSURE STATEMENT, NOTICE OF PRIVACY PRACTICES & OFFICE POLICIES
This is a statement of your rights and responsibilities for our therapeutic relationship. The RCW 18.19.060 and WAC 246-810-031 require counselors/therapists to provide written disclosure of the following requirements to clients before counseling/therapy begins.
Therapist: Heidi Halsey, MA, LMFT Washington State Licensed Marriage and Family Therapist: 020705 LF00001125
Education; Bachelor of Arts in Psychology, San Diego State University
Master of Arts in Marriage, Family, Child Counseling, Chapman University
Training and Experience: I have over 35 years of experience with in and out-patient psychological treatment in areas including: sexual abuse, substance abuse, relationship dependency issues, domestic violence/Batterer’s and victim’s treatment, mental illness, anxiety, depression, post-traumatic stress, anger management, domestic relationship issues, suicidal ideations/gestures/feelings/attempts, acting-out behavior, divorcing and blending families, parenting, crisis management, developmental and life cycle issues, couple issues, obsessive thoughts, compulsive behaviors, relaxation, personal growth, inner and inter-personal and relationship issues. I do counseling for counselors in training and businesses. I also do motivational and life change coaching and dating coaching.
Methods and Techniques: I use a wide range of therapeutic interventions and perspectives as a meta-therapist including family systems, behavior management techniques, communication skills and supportive counseling through the assessment of individuals and families within their particular social system. I will use whatever therapeutic orientations are the best match or combination for each client. Clients set the agenda and make their goals for treatment. Problems are clarified and areas of focus are selected to develop a clear understanding of what we will accomplish together. Through the counseling, alternative views, options or skills may be presented and reading and homework assignments are common. You are responsible for making progress and setting the tone and speed of therapy. It is necessary to bring up and address anything that goes on in the therapy process that you are uncomfortable with so that I can restructure sessions or responses to make you feel more comfortable so that you can make the progress, changes or recovery that you seek.
Therapy Delivery: It is most common to deliver services in my professional office. I also do tele-therapy which is a HIPPA secure platform of two-way live audio and visual stream. There are times where the government requires tele-therapy to be covered by ALL insurance companies (Spring 2020 – temporary). There are also temporary permissions to conduct sessions via facetime or zoom or non-HIPPA compliant platforms when HIPPA platforms cannot be achieved. When those rulings are not in place, most insurance companies in Washington cover and pay for tele-therapy. It is your responsibility to make sure your insurance policy and your insurance plan that your employer or union arranged, allows and pays for tele-therapy. During the Covid-19 Pandemic, all insurances are required to allow tele-therapy.
Therapy Process and Results or Outcomes: Participation in therapy can result in several benefits including improving interpersonal relationships and the resolution of the specific concerns that led you to seek therapy. Working toward these benefits requires effort on your part, including honesty and openness and ownership over the progression of therapeutic involvement and process. Therapy can include discussing uncomfortable events or feelings and I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed or disappointed – as well as other emotions. Psychotherapy may result in your making decisions about behaviors and relationships and while changes you make are with the goal of life improvement or the resolution of difficult or problematic relationships, behaviors or coping styles, some people in your life may not see your progress as positive and may view your changes as negative. Sometimes change is easy and swift while sometimes slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. Should you desire, I will refer you to another provider to continue therapy if my methods do not match what you would like from the therapeutic process.
Treatment Plan: I will discuss the specific goals and therapeutic objectives that you have in your pursuit of therapy. I will address possible risks and provide alternative suggestions to psychotherapy when appropriate.
Termination of Therapy: I reserve the right to discontinue therapy services if you fail to keep appointments, pay your fees incurred, be disruptive to other building tenants, be hostile, threatening or intimidating to me, my staff, other building tenants or other members of the treatment family or if I do not believe that I am qualified to assist you in reaching the goals you outline in your request for therapeutic services. Also, not everyone is ready or willing or capable of accomplishing therapy and I may decline to treat or continue treating you. I may not do therapy with actively abusive members of a marriage, family or relationship. I may provide additional referrals if termination occurs via agreement. If you discontinue therapy on your own or leave session without completing the session, you are terminating therapy yourself and can contact your insurance company for a new referral. I do not do therapy with people whose presenting or co-existing issues or conditions are not within my scope of expertise or where a specific specialty license is required to treat that population that I do not have.
Dual Relationships: Dual relationships between clients and psychotherapy providers are prohibited when they include social, financial or sexual involvement. Should we run into each other when out in the community, I will never reveal our therapeutic relationship. If we end up in the same activities or social groups without intent, we will discuss the situation in therapy and will discontinue the therapeutic process if involvement in the other environment appears to be interfering with the effectiveness of the therapeutic process. We will not have social media connections. We discourage public reviews as it voids your privacy. Making public reviews waives your privacy and allows us to respond to your review to correct, clarify or dispute information that you place in a public review. I welcome feedback directly to Heidi Halsey MA LMFT.
Fees and Payment
Your insurance sets what is allowable with the remainder written off by preferred providers.
YOU are responsible to check and confirm your insurance benefits and to what degree I am covered or not.
WE DO NOT DO BENEFIT CHECKS.
It is your responsibility to know if you have a deductible and how much of your deductible is met or remains PRIOR TO THE FIRST APPOINTMENT.
We will collect your copay and towards your deductible if applicable AT EVERY APPOINTMENT.
Initial Session $ 205
Individual/Couple/Family Session $ 155
Late Cancellation/No-Show Fee $ 75 - 9 am – 3:30 pm,
$ 100 4 pm and later & all Saturday appointments
Telephone Calls/emails/TEXTS / hour $ 150 if required for your safety or for best practices follow up
with you
Monthly billing for late accounts $ 5
Account sent to collection fees $ 150 for accounts under $400
$ 350 for accounts over $400
Fees for services are expected at the time of your visit. Payment is made directly to Heidi Halsey MA LMFT - preferably at the beginning of the session. Payment can be made at the www.heidihalsey.com website with debit / credit / or HSA cards, or by mailing a check or at Venmo Heidi-Halsey (picture of two dogs). I will bill your insurance company or EAP company directly for services rendered, if I am a provider for that insurance. If I am not a provider for your insurance, you must pay for the session and I will provide you with a superbill that you submit to your insurance for reimbursement. If for some reason, there is an over-payment, it will be applied to your account or refunded. As a contracted provider for some insurance companies, the contracted amounts required will be reduced from the amounts charged and you will only be charged what is legally allowed per my contract with your insurance company IF I am a contracted provider for your insurance company. If for any reason other than our billing mistakes, you will be responsible for the fees should your insurance company not pay what was anticipated. Disputes arising from billing associated with your counseling services should be addressed with me in writing through mail or secure email through the scheduling site.
Reminders: Reminders will be automatically sent by the scheduling program to your email or phone via automated message or text per your choice in the scheduling program registration. Reminders go out the morning two days prior to the appointment. Occasionally, system issues with servers interfere with reminders going out but you still are expected to show. Reminders are a courtesy. You can always login the scheduling program and check your scheduled appointments to confirm it yourself. Not receiving a reminder does not waive your commitment to the appointment. Appointments scheduled after the scheduling program window of when reminders go out for your appointment means you will not receive a reminder for that appointment.
Appointments – Most therapy appointments are scheduled to last 50 -55 minutes or as otherwise arranged between us and occur within the hour scheduled. Appointments are set to begin 5 minutes after scheduled time to allow the full time. Because I deal with difficult situations, your appointment may begin 5 – 10 minutes after you are scheduled. You will still receive your full time. If you are unable to keep your scheduled appointment, please cancel online or via text or voicemail at least 24 hours in advance for all appointments scheduled between 9 am and 3:30 pm, and 48 hours’ notice for appointments scheduled 4 pm or later or on Saturdays. All clients who don’t show for scheduled appointments or cancel with less than 24 hours’ notice that are scheduled between 9 am and 3:30 pm will be charged $75. All clients that don’t show for appointments scheduled for 4 pm or later, or on Saturday, and cancel with less than 48 hours’ notice, will be charged $100. Unfortunately, I cannot have a flexible policy that allows me to decide to not charge some people for late cancellations because of their situation and charge others with different reasons. All no show and late cancellation fees must be paid at the next appointment or within 30 days.
Contact & Messages – I do not do any form of phone or text or email therapy. The quickest way to get into contact with me is to message me through the scheduling system and in emergencies or for rescheduling, via text at 253-446-9222. All messages must be sent using the encrypted emails through my scheduling program at WWW.TherapyAppointment.com. I do not do email therapy and I do not encourage emails. I do not schedule appointments through emails or via text. I will not and cannot respond to emails presenting therapeutic issues, or emails updating me to your situation.
Treatment to Minors – If you are under the age of thirteen please be aware that your parent may examine your treatment records. I will attempt to work with you and your family on your behalf with the permission granted in the ‘no secrets agreement’ signed by all family members acknowledging that family therapy requires contact and discussion with all members in various formats, all together, some individually, some in smaller units of the family whether or not you are under or over the age of 13, so as to improve your situation individually and within your family. If you are 13 – 17, your parent(s) or legal guardian or person acting as your primary caretaker may arrange 12 sessions for you within a 3-month period without your consent. If in place, a parenting plan copy must be in the minor’s file. If joint decision making is listed on a parenting plan, then both parents must consent to therapy for minors 12 and under or for minors 13 and over who do not consent to treatment.
Consultations: I regularly consult with other professionals regarding clients on my caseloads. This allows me to gain other perspectives and ideas as to how to best help you reach your goals. These consultations are conducted in such a way that confidentiality is maintained, your name is not given nor is other identifying information.
Confidentiality: Your treatment here is confidential. Information about you can only be released if it is specifically authorized by you with a written Release of Information form / ROI. This ROI can be revoked at any time at your request. I am required by law to release confidential information in selected cases. This can occur when there is suspected abuse or neglect of children or dependent adults, a threat or perceived threat of a danger to self or others, or the inability to meet basic personal needs. In some situations, the courts may subpoena treatment records. I also do not return emails or phone calls from friends or family members or acquaintances that attempt to contact me to provide information or request information on your behalf as this would constitute a violation of your privacy. I do not see other clients if it presents a conflict of interest. Each situation is individually considered. Please be aware that your insurance company and the Washington State Department of Health have the liberty to request a complete copy of your counseling file at any time. If you choose to not have me maintain a file with notes of our visits, a separate form will be required for that request. Any complaints to the Better Business Bureau cannot be responded to as it again, would violate confidentiality.
Be aware that email and cell phone communication can be relatively easily accessed by unauthorized people and the privacy and confidentiality of such communication can be compromised. Emails, texts, faxes and voice messages will be sent to numbers you authorize for communication between us. Please see the Notice of Privacy Practices for the office of Heidi Halsey LMFT.
Health Insurance & Confidentiality: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. I have no control or knowledge regarding what your insurance company does with the information. No clinical session notes will be provided to your insurance carrier orHMO/PPO/MCO/EAP, without your additional written consent. Please be aware that the failure to provide required information to the company responsible for claims paying for your counseling may result in the company refusing to pay your claim. Please be aware that in this situation, you will be responsible for all service fees incurred.
Records Requests: We keep a record of the counseling services we provide you. You may ask us to see and obtain a copy that record. You may also ask us to correct that record. You may get a record copy by making request in writing via written letter mailed to my business address, or through the encrypted email service on my scheduling program. You will then need to complete our Counseling Record Request Form. You will be notified of the fees for the record copy and they will need to be paid prior to the record copy being released to you or mailed to you. If you want to look at the record, you will need to schedule an appointment and pay the standard office visit fee of $155 – which cannot be billed to the insurance and which is due at the time of scheduling the appointment for record review. 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 and when an ROI / Release Of Information form is signed by you and is specific as to WHO you want information released to and WHAT information you want released. There are charges for this process as set by the State of Washington: RCW 70.02.010(37) allows health care providers to charge fees for searching and duplicating health care records. The fees a provider may charge cannot exceed the fees listed below:
$1.17 per page for the first thirty pages; and 88 cents per page for all other pages; and a
$26 clerical fee for searching and handling records; and
$155 for the provider to personally edit confidential information from the record, as required by statute, as the provider can charge the usual fee for a basic office visit.
If you have counseling with any other person, all people involved MUST consent to any person or agency that requests to view or receive a copy of your record, except when I am required to release records required by legal or law enforcement agencies, your insurance company or the Department of Health.
Court Proceedings and Litigation Limitations: It is the policy of Heidi Halsey MA LMFT, to not voluntarily be involved in court proceedings or to make recommendations regarding parenting or mental health issues in legal proceedings. These services are provided for mental health, behavioral health, skill improvement, emotion or trauma processing and life improvement or symptom reduction purposes. These services are not provided to assist with any current or future legal case. This document details the agreement that you nor any attorney or anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested for any legal proceeding including but not limited to: divorce, dissolution, custody disputes, injuries, L & I, lawsuits etc. Should I be subpoenaed on your or your children’s behalf in any situation, you acknowledge that I am an Expert Witness and that a retainer of $2500 will be paid when servicing the subpoena to cover the rate of $250 per hour for case review and preparation, any necessary consultation or letters and testimony if I am so forced. The fee of $250 per hour covers all scheduled travel time, deposition time, court appointments, time waiting at court – even if hearings do not occur if not cancelled entirely 7 days prior. The fees will be billed out weekly and must be paid within 7 days upon receiving the invoice. The person or the person’s attorney who is issuing the subpoena is responsible for paying these fees. Understand, because of my licensure, an attorney signed subpoena must be preceded by a letter that a subpoena is going to be served. Additionally, because of the confidentiality, your information is PRIVILEDGED and you must WAIVE your PRIVILEDGE resulting in a COURT ORDER signed by a JUDGE for my information to be released for legal purposes to an attorney or via deposition or Court. You may also assert your PRIVILEDGE and request to the Court that your information NOT be released. Both people involved in couples therapy must wave or assert privilege. These are laws that govern therapists and the protection of confidential and privileged information.
Emergency Procedures – If you need to contact me between sessions, please leave a message through the secure provider scheduling website. Please additionally consider calling your primary medical health provider, 911, the Pierce County 24-hour Crisis line at 253-798-4333 or present yourself at your local emergency room. If I am out of town, instructions for contacting a provider with the equivalent counseling licensure will be provided on my office telephone answering message. In the event of an emergency, you may also call the Crisis Clinic at (206) 461 – 3222 (King County) or (253) 798 – 4333 (Pierce County), Lifeline 1-800-273-8255, Https://www.crisistextline.org, https://866teenlink.org & phone 866-833-6546, In crisis and in the US? Text HOME to 741741.
Consumer Rights/Ethical Protection – As a consumer you have certain basic rights as follows: you have the right to receive appropriate care and treatment, employing the least restrictive alternatives available; the right to choose a counselor who best suits your needs and purposes; the right to be treated with respect and dignity; the right to receive treatment which is non-discriminatory and sensitive to difference of race, culture, language, sex, age, national origin, disability, creed, socioeconomic status, sexual orientation; the right to an individualized treatment plan reflecting problems and/or needs identified with you; the right to confidentiality; the right to refuse any proposed treatment; the right to review your case record under specified conditions; the right to be free of any sexual exploitation or harassment; and the right to lodge a grievance if you feel you have been violated. Complaints about the work or ethical behavior of any counselor can be directed:
Washington State Department of Health
Health Systems Quality Assurance Complaint Intake
P.O. Box 47857
Olympia WA 98504-7857
(360) 236-4700
http://www.doh.wa.gov/hsqa/Complaint.htm
“Counselors practicing counseling for a fee must be registered or licensed with the Department of Licensing for the protection of the public health and safety. A registration of an individual with the department does not include recognition of any practice standards nor necessarily implies the
effectiveness of any treatment.”
SERVICE CONSENT
I (we) voluntarily consent to mental health services provided by Heidi Halsey, LMFT and I understand and have received all policy information including information on consumer rights/ethical protection, disclosure information, confidentiality, appointments, and fees/payment policies.
I (WE) HAVE READ THE ABOVE GUIDELINES PRESENTED TO ME BY Heidi Halsey, LMFT AND AGREE TO AND UNDERSTAND THESE TERMS. I ACKNOWLEDGE THAT I AM RESPONSIBLE FOR ALL FEES INCURRED IN COUNSELING AND THAT I AM FURTHER RESPONSIBLE FOR ALL NECESSARY COLLECTION, ATTORNEY AND LEGAL FEES INCURRED IN ATTEMPT TO COLLECT THESE FEES FOR ME, OVER AND ABOVE THE FEES CHARGED. CONFIDENTIALITY IS NOT BROKEN WHEN CLIENTS ARE REFERRED TO COLLECTION SERVICES BECAUSE ONLY FINANCIAL INFORMATION IS RELEASED. Clients assume all financial responsibility for any willful accident or accidental damage done to the property or premises and release Heidi Halsey, LMFT from liability from any physical injury sustained in an accident or during the commission of vandalism or violence.
NO SECRET AGREEMENT
This written policy is intended to inform you, clients in individual therapy, family therapy, couple therapy, or parents who are requesting services for their minor children, that while I, Heidi Halsey LMFT, agree to work with you, I consider the family, couple, or parent and minor child(ren) [the treatment unit] to be the patient. During the course of work with a couple or a family, I may see a smaller part of the treatment unit (e.g., an individual or two siblings) for one or more sessions. These sessions should be seen by you as a part of the work that I am doing with the family or couple, unless otherwise indicated. If you are involved in one or more of such sessions, please understand that generally these sessions are confidential in the sense that we will not release any confidential information to a third party unless we are required by law to do so or unless we have your written authorization. For instance, if there is a request for the treatment records of the individual, couple or family, I must by law, seek the authorization of all members of the treatment unit before we release confidential information to third parties. Also, if records are subpoenaed, I will assert the psychotherapist-patient privilege on behalf of the patient(s) [the treatment unit]. However, I may need to share information learned in an individual session (or a session with only a portion of the treatment unit being present) with the entire treatment unit – that is, the family, the couple or the parent(s), if I am to effectively serve the unit being treated. I will use my best judgment as to whether, when, and to what extent, I will make disclosures to the treatment unit, and will also, if appropriate, first give the individual or the smaller part of the treatment unit being seen the opportunity to make the disclosure. Thus, if you feel it necessary to talk about matters that you absolutely want to be shared with no one, you might want to consult with an individual therapist who can treat you individually.
This “no secrets” policy is intended to allow me to continue to treat the patient (the couple or family unit) by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the unit being treated. For instance, information learned in the course of an individual session may be relevant or even essential to the proper treatment of the couple or family. If I am not free to exercise clinical judgment regarding the need to bring this information to the family or the couple during their therapy, I might be placed in a situation where I will have to terminate treatment of the couple, the family or the minor child. This policy is intended to prevent the need for such a termination. We acknowledge by our individual signatures below, that each of us has read this policy, that we understand it, and that we have had an opportunity to discuss its contents with our therapist and that we enter therapy in agreement with this policy.
Please read the What to expect flier distributed by the Washington State Department of Health. A copy will be included in your intake paperwork.
website: https://www.doh.wa.gov/portals/1/Documents/Pubs/670125.pdf