Document Sample
					                                           RAINIER ASSOCIATES
                                                5909 Orchard West
                                            Tacoma, Washington 98467
                                        253-475-6021 * 253-474-1871(FAX)

J. Dale Howard, M.D.                                                    Clinical Associates
Barry S. Anton, Ph.D., ABPP                           Emily Schoenfelder, M.S.W.          Catherine A.J. Mulhall, M.S.W.
                                                      Naomi Huddlestone, Ph.D.            Vanessa Honn, Ph.D.
                                                      Fletcher B. Taylor, M.D.            Ryan Coon, Psy.D.
                                                      Trenton J. Williams, Ph.D.          Karen Kellums, Psy.D
                                                      Susan J. Poole, Ph.D.               Lois Stevens, LICSW
                                                      Nagavedu Raghunath, M.D.            Jodi Howell, Ph.D.
                                                      George Jackson, M.D.                Amy Dwyer, M.S.W., LICSW
                                                                                          EJ Kasler, M.N., A.R.N.P.

Emily Schoenfelder, MSW, ACSW
       Washington State law requires that I share the following information with you and that you indicate you
have been informed by signing one copy of this form. Please read the following information carefully. I
welcome the opportunity to discuss any questions or concerns you may have regarding this agreement or my

CREDENTIALS: I hold a Bachelor’s Degree in Social Work from the University of Oregon (1976) and a
Master’s Degree in Social Work from the University of Washington (1979). I have worked in agencies and
private practice since 1978. My professional experience includes individual, couple and group therapy in the
treatment of adults, adolescents and children.

I am a member of the National Association of Social Workers, the Academy of Certified social Workers, the
Washington State Society of Clinical Social Workers and am board Certified by the National Board of
Examiners in Clinical Social Work (#8038) and the National Registry for Group Psychotherapists. I am
licensed by the State of Washington as a certified Social Worker (020704) and a Certified Marriage and Family
Therapist (020705). I ascribe and adhere to the Code of Ethics of the NASW and to the ethical and professional
standards of the Washington State certification law.

MY METHODS OF THERAPY AND APPROACH TO THERAPY: My approach to therapy is one of helping
people look at patterns of behavior that are maladaptive and finding alternatives for them. This process may
involve exploring past family and personal relationships, understanding how you interact within your
interpersonal “systems” and learning new, more adaptive methods to help you achieve your goals. I see myself
in the role of a facilitator, who challenges old behaviors and ideas, and encourages you to create new ways to
solve problems.

Each therapy is unique to those who participate in it. Thus, your therapy will be a blend of what you and I do
together. I am responsible for developing and implementing a course of treatment that will most effectively
deal with your issues. You are responsible for your decisions and for changing. People and situations are
complex; no counselor can guarantee that specific changes will occur as a result of our therapy together.

You always have the right to request a change in treatment or to refuse treatment. It is essential that what we do
together meet your needs. If you believe you are not being helped, please tell me so that we can work through
that difficulty together. If we are unable to do so I will assist you in finding another therapist.

CASE CONSULTATION AND REFERRAL SOURCES: In some cases it will be useful to the therapy to
discuss your situation with others, such as a physician, a former therapist, a teacher or a referral source, etc. In
that case, I will seek your permission for the exchange of information and a written “Release of Confidential
Information”, signed by you, will be filed (written permission to discuss your case with other health care

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providers is not necessary in all situations; see “Confidentiality & Medical Records” section that follows). On
occasion, I consult with colleagues about my work with a particular client to gain further feedback and
suggestions about treatment. In no case will your name be given or unique information be used in consultation.

If you have been referred to me, I may, as a good business practice, acknowledge that you have made contact
with me and thank the referring party. I will not discuss your situation unless I have your written permission.

APPOINTMENTS: Your appointment time is held exclusively for you. Individual and couples therapy
appointments are 45 minutes in length. It is important that you arrive on time for your appointment, as it cannot
be extended. If you are unable to keep your appointment for any reason, please contact me at least 24 hours in
advance to cancel or reschedule; otherwise you will be charged $50.00 for the missed session.

EMERGENCY CALLS: An answering service takes all emergency calls outside of regular business hours.
This service will attempt to locate me in the event of an emergency and will contact the on-call clinician if I am
not available.

FEES: My fees are $195 for the initial consultation hour, then $165 per hour, regardless of the number of
people attending the session.

BILLING AND PAYMENTS: Please remember that fee payment is your responsibility. I request that you keep
current with your portion (the part insurance does not cover) each session or at the end of each month. If you
are unable to manage this, please work out a payment arrangement with me in advance. Ultimately, you are
responsible for your account and are expected to pay your bill, whether insurance pays for a portion or not. A
finance charge of 1% per month may be added to any balance not paid within 60 days after the charge is
incurred. If 90 days pass without a payment, accounts may be sent for collection. If you have any questions
about your account, please ask me or my bookkeeper.

INSURANCE: I am a contracted provider for many, but not all, local insurance companies. You should be
sure to check with your insurer and my intake office to learn whether I am a provider for your plan. You should
also learn whether you need a referral or preauthorization in order to be eligible for your mental health benefit,
whether you have a separate annual deductible for mental health, and whether your mental health benefit has a
maximum yearly number of visits or a maximum yearly dollar amount. My billing department will submit
claims to insurance companies that I am contracted with. In order for this to occur you must complete the
insurance portion of the “Patient Information” form that was given to you with this office policy; you also need
to provide a copy of your insurance card.

CHANGES TO THIS OFFICE POLICY: From time to time I may change the business policies described in
this document; I will attempt to inform you of relevant changes.

CONSENT FOR TREATMENT: I have read Emily Schoenfelder’s Office Policy Statement and understand it.
I consent to therapy under the terms described above and understand that I have the right to terminate treatment
at any time. My signature below indicates I have received a copy of this agreement.

Please print your name: ________________________________________

Please sign your name: _________________________________________                    Date: _________________

Emily Schoenfelder, M.S.W.,A.C.S.W.                                  Date

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                          CONFIDENTIALITY & MEDICAL RECORDS
       This document contains important information about your rights regarding confidentiality and your
medical records. Please read it carefully, as you did my office policy. Make a note of any questions you might
have so we can discuss them. When you sign this document, it will represent an agreement between us.

CONFIDENTIALITY: The State of Washington, and the federal Health Insurance Portability and
Accountability Act (HIPAA), allow most issues discussed with me to remain confidential. These laws protect
your right to privacy. For example, the information that I record in my psychotherapy notes is protected by
HIPAA and cannot be used or disclosed without your specific, written authorization (there are a few exceptions;
please see below).

        Other health information is provided somewhat less protection by state and federal law. Examples
include information pertaining to medication prescription and monitoring, counseling session start and stop
times, dates of treatment, results of clinical tests, and summaries of your diagnosis, functional status, the
treatment plan, symptoms, prognosis, and progress to date. This information is called Protected Health
Information (PHI) because it is still safeguarded and can be released only in limited circumstances and for
specific reasons. In particular it may be used or disclosed for purposes of treatment, payment, or health care

– Treatment involves the provision, coordination or management of your health care and other services related
to your health care. An example of treatment would be my consulting with another health care provider, such as
your family physician or another counselor.
- Payment involves the reimbursement of RA for your healthcare. This can include the disclosure of your PHI
to your health insurer, when required, to obtain reimbursement or to determine benefit eligibility or coverage.
- Health Care Operations are activities that relate to the performance and operation of my practice. Examples
of health care operations are quality assessment and improvement activities, business-related matters such as
audits and administrative services, and case management and care coordination.

By signing this document you provide your consent for me to use and disclose your PHI for these three

       There are some instances in which your right to confidentiality is automatically waived. Any or all of
your health information, including anything in my psychotherapy notes, may be released, even without your
consent or written authorization, in the following circumstances.

   If I become aware that you or another person may be abusing, exploiting or neglecting a child under age 18,
    a dependent adult, a developmentally disabled person, or an elderly person, a report must be made to the
    appropriate authorities (RCW 26.44).
   If you become a danger to others, I must protect the other person(s) and you by warning the other person(s)
    at risk and report the danger to the appropriate authorities (RCW 71.05.120).
   If you become mentally ill and become unable to take care of your basic needs or become a danger to
    yourself or others and also refuse treatment, I must report your condition to the authorities (RCW 71.05).
   If you tell me that you are suffering from HIV-related illness and do not have a physician providing for your
    care, I must report the identities of your IV drug-using or sexual partner(s) to the local health care officer
    (WAC 248-100-072).
   If my professional licensing board subpoenas me as part of its investigations, hearings or proceedings
    relating to the discipline, issuance or denial of licensure of state licensed professionals, I must comply with
    its orders and disclose your relevant mental health information (RCW 18.130.180).
   If you are involved in a court proceeding and a request is made for information about the professional
    services that I have provided to you and the records thereof, such information is privileged under state law
    and I will not release information without the written authorization of you or your legal representative or a

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    court order signed by a judge. The privilege does not apply when you are being evaluated for a third party
    or where the evaluation is court-ordered. You will be informed in advance if this is the case (RCW
    18.83.110, RCW 71.05.390, and RCW 71.05.630).
   If you file a worker’s compensation claim, with certain exceptions, I must make available upon request, at
    any stage of the proceedings, all mental health information in my possession relevant to that particular
    injury (in the opinion of the Washington Department of Labor and Industries) to your employer, your
    representative, and the Washington Department of Labor and Industries (RCW 51.36.110).

    In all other instances, beyond those listed above, I will obtain an authorization from you before using or
disclosing any of your health information. A valid authorization must be written and signed by you and specify
the recipient of the information (including the institutional affiliation of this individual) and the particular
information to be used or disclosed. For example, if you would like me to speak with a family member, you can
complete an “Authorization to Disclose” form. A written authorization is valid for no longer than 90 days from
the date you sign it. You may revoke an authorization at any time, as long as the revocation is in writing. You
may not revoke an authorization for information that has already been disclosed based on that authorization.
Neither may you revoke an authorization that was obtained as a condition of obtaining insurance coverage.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION: You have the following rights concerning
the health information that I maintain about you (for a minimum of 7 years after your last visit).

Right to Request Restrictions –You may request restrictions on certain uses and disclosures of PHI. I may deny
your request under certain circumstances, but in some cases you may have this decision reviewed.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – For
example, if you did not want your family to know that you are in treatment, you could request that we send your
bills to another address.
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy
notes. This request must be made in writing and, if you request a copy of the information, you may be charged
a fee for the associated costs (e.g., copying). I may deny your access to this information under certain
circumstances, but in some cases you may have this decision reviewed. Because the information in
psychotherapy notes is sensitive and potentially upsetting, I strongly recommend that you review these notes
with me, should you choose to request a copy.
Right to Amend – If you feel that the information I have about you is incorrect, you may ask that I amend the
information. I may deny your request under certain circumstances. In some cases you may have this decision
Right to an Accounting of Disclosures – You may request a list of the individuals or agencies to whom your
health information has been disclosed, unless the disclosures were made for treatment, payment, health care
operations, or were made to you or following a written authorization given by you.
Right to Complaints – If you are concerned that either Rainier Associates or I have violated your privacy rights
or you disagree with a decision made about access to your records, you may contact our office manager at 253-
475-6021. You may also send a written complaint to the Secretary of the U.S. Department of Health and
Human Services; this address will be provided upon request.
Right to a Copy of this Document – You may receive a copy of this document upon request.

INFORMED CONSENT: Your signature below indicates that you have read the information in this document
and agree to abide by its terms during our professional relationship.

Please print your name: ______________________________________________

Please sign your name: _______________________________________________                    Date: _____________

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