We’re Hiring! Now taking applications for a new therapist to join our team. Learn More
"*" indicates required fields
Provision of the following information and written acknowledgement of its receipt are required by Washington State Law. Please read carefully.
Mental health counselors practicing counseling for a fee must be licensed. Any counselor that you meet with at PEOPLEinc. is licensed.
Your Rights as a Client in Counseling:
As a client of a counselor licensed by the State of Washington, you have privileged communications under the law. With the exceptions listed below, you have the right to confidentiality. This right cannot be waived without your specific written consent.
You always have the right to change or refuse treatment. It is important that we work together in order to meet your needs. You may terminate therapy at any time; however, I believe it is of great value to you to discuss the decisions, reasons and process for termination with me prior to terminating.
Our Training and Approach:
Our preparation and education includes a Master’s Degree and/or Ph.D. with a concentration in Counseling.
We use a variety of approaches to counseling. Each therapist has their unique style of working effectively with clients to achieve the highest level of success. Any methods used are consistent with generally accepted theory and practice.
Sessions and Fees:
Sessions are scheduled for 50 minutes. Fees charged per session are $175 and/or other negotiated amounts that are unique to specific insurance plans. Payment is due at the beginning of each session. Should you need to reschedule or cancel an appointment we request a notice of 24 hours, otherwise, it will be necessary to charge for the time that has been reserved for your session. The charge for a session that you do not show up for or cancel with less than a 24 (business) hour notice will be billed at $175. Under this policy, sessions on Monday require cancellation the Friday prior. Please be aware that if your sessions are covered under your insurance provider; they will not reimburse for missed appointments. Therefore, it will be your obligation to pay for any missed appointments that have not been cancelled or rescheduled within the 24-hour notice referred to above. Any outstanding balances are charged late fees of $25 per month.
Signature is required for client 13 or older and for parent or guardian of client 12 or younger
If you or your dependent child is in treatment with one of our clinicians that is licensed as an Associate level clinician, that clinician will be under the direct supervision of an authorized supervisor. Your signature on this form indicates your understanding and approval of that.
If you are signing this agreement for a minor child, please be advised that it is your responsibility as their parent/guardian to have them show up for their scheduled appointments. It is not the responsibility of their clinician to reach out to you or attempt to track down the client for attending any sessions. The clinician's only responsibility is to show up at the agreed upon time and date to hold that session with the client. Just as it would be for any other client; adult or child. No show or late cancellation charges apply the same in these circumstances, as stated in another part of this agreement.
If you would like us to bill on your behalf, please provide us with your insurance card to copy. We will bill your insurance as a courtesy but it is ultimately your responsibility to be sure that payment is made for your services. If we bill your insurance and they do not pay, it is your responsibility to pay for your services and any discrepancies with your insurance reimbursement will be yours to clear up with them directly.
Please also be sure to obtain any prior authorizations that may be required for your insurance to pay for this and future visits.
I authorize the release of all medical records to my insurance company. I further authorize insurance payments to be made directly to PEOPLEinc. I understand payment is due at time of service, even though we may choose to delay receipt until your insurance has been billed.
3401 Evanston Ave N, Ste DSeattle WA, 98103425-880-4333
4462 Preston Fall City Road SE,Fall City, WA 98024425-880-4333
23639 126th Ave SEKent, WA, 98031425-880-4333
Copyright 2023, PEOPLEinc.