Disclosure by LekqG4


									                        Michelle S. Peadon M.A., LMHC- A
                      Individual, Marriage and Family counseling
                                        1160 140th Ave NE
                                       Bellevue, WA 98005
                                          (425) 221-3582


Welcome. This information has been prepared to acquaint you with my office policies and
procedures. It also contains summary information about the Health Insurance Portability and
Accountability Act (HIPAA), a federal law that provides new privacy protections and new
patient rights with regard to the use and disclosure of your Protected Health Information used for
the purpose of treatment, payment, and health care operations. HIPAA requires that I provide
you with a Notice of Privacy Practices for use and disclosure of your information for treatment,
payment and health care operations.

I am a Licensed Mental Health Counselor Associate in the state of Washington. I treat
individuals, couples, and families. I received my Master’s degree in Counseling Psychology
from Northwest University.

My theoretical orientation is based on a belief that effective treatment involves understanding
one’s thoughts, feelings, and behaviors, which enables the challenging of old negative voices and
patterns of relating that are problematic. I believe this is accomplished by developing a strong
therapeutic relationship where both the client and therapist are involved in the exploration of past
and present relationships to gain a better understanding of the client’s current relationship
patterns. There are many approaches to psychotherapy, but research consistently shows that the
most important predictor of success is the relationship between the therapist and client. I believe
that treating all of my clients with the utmost dignity, care, and honesty, lays the foundation for
growth and change. In my work with clients, I use a variety of counseling methods and

My fee is currently $110 for a 50 minute therapy session. Payment in the form of check or cash
is expected at the time of service. I am not set up to take credit cards. Also, it is helpful if you
can have your check made out prior to the session so we don’t have to use valuable session time
for that.

Each session is 50 minutes. When you make an appointment with me, that time is exclusively
yours. If you need to cancel an appointment, please do so at least 48 hours in advance.
Cancellations made less than 24 hours in advance will be charged full fee.
                                                            Michelle S. Peadon, MA, LMHC-A

I will provide you with a receipt of our session that includes a diagnostic code. You may submit
this to your insurance company for reimbursement. I would be considered an ‘out of network’

Your therapy is confidential. The law protects the privacy of all communications between a
patient and a therapist. In most situations, I can only release information about your treatment to
others if you sign a written authorization form that meets certain legal requirements imposed by
state law and/or HIPAA.

       With your signature on a proper authorization form, I may disclose information in the
       following situations:
        1. I sometimes consult with a supervisor or other mental health professionals to insure
            the best possible treatment for you. When I do, I make every effort to avoid revealing
            your identity. These professionals are legally bound to keep the information
            confidential. If you do not want me to consult about your case, please let me know.
        2. If you are involved in a court proceeding and a request is made for information
            concerning the professional services I provided you, although the law does not
            protect such information by therapist - patient privilege, I cannot provide any
            information unless 1) you give me written authorization; or 2) a court order requires
            the disclosure. You may seek a protective order against my compliance with a
            subpoena that has been properly served on me and of which you have been notified in
            a timely manner,
        3. If you are involved in or contemplating litigation, you should consult with your
            attorney about likely required court disclosures.

       There are some situations where I am permitted to disclose information without either
       your consent or authorization: If a patient files a complaint or a lawsuit against me, I may
       disclose relevant information regarding that patient in order to defend myself

       There are some situations in which I am legally obligated to take action in an attempt to
       protect you or others from harm. These situations are unusual in my practice.
       1. If I have reasonable cause to believe that a child has suffered abuse or neglect.
       2. If I have reasonable cause to believe that abandonment, abuse, financial exploitation,
            or neglect of a vulnerable adult has occurred.
       3. If I reasonably believe that there is an imminent danger to the health or safety of the
            patient or any other individual, I may be required to take protective actions. These
            actions may include notifying the potential victim, contacting the police, seeking
            hospitalization for the patient, or contacting family members or others who can help
            provide protection.
* If such a situation arises, I will make every effort to discuss it with you before taking
  action, and I will limit my disclosure to what is necessary

                                                            Michelle S. Peadon, MA, LMHC-A

If you choose to use technology (primarily email) to correspond with me, it is important to
understand that your information may not be secure in cyber space as I do not have an encrypted
website. I do have a password protected email account and I use password protected access for
logging onto my computer.

In the unlikely event that I am no longer able to provide services, your file will be turned over to
Jorgan Peadon who will contact you to provide a referral for another therapist. He will keep your
records for 5 years. His number is: 253-797-0950.


You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in
a professional record. It includes information about your name, dates of service, fees, a
description of the services provided, your diagnosis, your treatment history, any past treatment
records that I receive from other providers, reports of any professional consultations, your billing
records, and any reports that have been sent to anyone, including reports to your insurance
carrier. You may examine and/or receive a copy of your Clinical Record, if you request it in
writing, except in the unusual circumstances that I conclude disclosure could cause danger to the
life or safety of the patient or any other individual. A copy fee may apply.

You have the right to:
*Request restrictions on how I use and share your health information. I will consider all requests
for restrictions carefully but I am not required to agree with all of the restrictions.
*Request that I use a specific telephone number and address to communicate with you.
*Request amendments or additions to your health record.
*Request an accounting of certain disclosures of your health information made by me.
*All of these requests must be made in writing.

You may also file a written complaint with the Office of Civil Rights of the U.S. Department of
Health and Human Services in Olympia, Washington.


Your signature below indicates that you have read this agreement and agree to its terms. It also
serves as an acknowledgement that you have received the HIPAA brochure, my disclosure
statement, a statement of confidentiality, and the notice of privacy practice.
                                                          Michelle S. Peadon, MA, LMHC-A

Client                            Date

Client                            Date

_______________________________________                    ______________________________
Client (If minor)                 Date                     Parent/Guardian          Date

Witness (Therapist)               Date


Your signature below indicates your consent for Michelle S. Peadon to consult with a clinical
supervisor as needed to ensure the highest quality of care.

Client                            Date

Client                            Date

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