Kim Richan, MSW, LSWA-IC
2915 E. Madison
Seattle, Washington
206-708-4622
This information is given in compliance with the Washington State regulation requirement, according to
RCW 18.19 [and in preparation for licensure under RCW 18.225]. I am a Washington State Licensed
Social Work Associate – Independent Clinical and my license number is SC60113506.
My education includes a Master’s degree in Social Work from the University of Washington. The goal
of my work is to help people in emotional distress gain relief from their distress through short-term and
long-term psychotherapy. In preparation for becoming a licensed independent clinical social worker and
as a part of my ongoing training, a senior clinician supervises my work.
My clinical practice is based on psychodynamic theory, which promotes the idea that in therapy,
emotional relief comes from the increasing insight, perspective, and awareness that is generated by
discussions between therapist and patient during the therapy hour. I welcome your questions about the
benefits and risks of treatment as well as alternative therapies you may also find useful.
Please confirm by initialing here _______ that you are aware I am available to discuss the benefits
and risks of treatment as well as the availability of alternative therapies.
My work with patients complies with all regulations as set forth by the state of Washington in RCW
18.19. If you wish to review the professional record for social workers or other allied mental health
professionals, you may do so at the Department of Health website, www.doh.wa.gov.
Payment: I do not accept insurance reimbursement at this time and my fee is $90 per 45-minute
session. A sliding fee scale is available for a limited number of patients on limited incomes. Payment is
due at the beginning of each session.
Confidentiality: I do not disclose information about my work with clients, except when required by
state or federal law. I will not disclose any other information about my clients without the written
consent of the patient.
Cancellation Policy: I allow 5 uncharged cancellations per year with at least 24-hour notice by phone.
Cancellations beyond 5 (within a calendar year) will be charged the full session rate. No show
appointments and appointments cancelled after the 24-hour window has elapsed are charged the full
session rate. This policy assumes weekly sessions. I will develop individual policies with clients seeing
me less frequently than weekly.
____________ Please confirm your understanding of this cancellation policy by initialing here.
Kim Richan Date
Signature of Client Date