Jill Joanis, MA LMHC CMHS
924 7th Ave NE Olympia, Washington 98501
(360) 339-2253
Washington State Licensed Mental Health Therapist (LMHC) # LH60087706
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Disclosure Statement and Agreement for Services
You have the right to refuse any treatment you do not want, and the responsibility to choose a mental health provider and treatment modality which best suits your needs. You also have the right to terminate your treatment at any time for any reason. The following information is provided to help you determine if what I offer as a mental health counselor meets your needs as a client. This document contains important information about my therapeutic approach, my education, my fees, and your rights as a client including your rights regarding your private health information. Please read this document carefully and ask any questions that help you fully understand the contents of this disclosure statement and agreement for services.
My Education, Training, and Experience
I am a Mental Health Counselor licensed by Washington State (Credential Number LH60087706). I have a Bachelor of Arts degree from The Evergreen State College with an emphasis of study in Multicultural Counseling. I graduated from Saint Martin’s University in 2006 with a Master of Arts in Counseling Psychology. Ongoing education is very important to me. I regularly attend and sometimes facilitate trainings in mental health treatment.
Therapeutic Philosophy
Treatment interventions are designed for each individual, family or group based on diagnosis, individual learning and expression styles, and relational dynamics. To achieve the maximum benefit from therapy, I will often encourage home practice, reading and exposure exercises. My counseling methods include interventions based in Cognitive Behavioral Therapy, EMDR (Eye Movement Desensitization and Reprocessing), Mindfulness Based Cognitive Therapy, Expressive Arts therapies, Psychodrama, Family Systems, Self-Generation Therapy,Dialectical Behavioral Therapy and Solution Focused Therapy. I have trained extensively in trauma treatment therapies and have completed requirements to be a Children’s Mental Health Specialist in the State of Washington.
I cannot guarantee that my counseling interventions will eradicate any specific problem or symptom. I provide tools, a supportive relationship and an environment for you, the client(s), to explore healing. I encourage you to take responsibility for your experience in counseling and the follow-up work you do outside of our sessions. If there is a counseling approach you don’t feel is helpful or a conflict you sense between us, please speak to me. Your success in therapy is directly related to feeling that what we do here is useful.
Confidentiality
Your participation in therapy, the content of our sessions, and any information you provide to me during our sessions is protected by legal confidentiality. Some exceptions to confidentiality are the following situations in which I may chose to, or be required to, disclose this information:
- If you give me written consent to have the information released to another party;
- In the case of your death or disability I may disclose information to your personal representative;
- If you waive confidentiality by bringing legal action against me;
- In response to a valid subpoena from a court or from the secretary of the Washington State Department of Health for records related to a complaint, report, or investigation;
- If I reasonably believe that disclosure of confidential information will avoid or minimize an imminent danger to your health or safety or the health or safety of any other person;
- If, without prior written agreement, no payment for services has been receive after 90 days, your name and past due amount may be submitted to a collection agency;
- If I have any other legal duty, obligation, or right to report.
I may also be required by law to disclose certain confidential information including suspected abuse or neglect of children under RCW 26.44 and RCW 18.19.180(3), suspected abuse or neglect of vulnerable adults under RCW 74.34, or as otherwise required in proceedings under RCW 71.05.
If you have any questions regarding your confidentiality, the limits of confidentiality, or the exceptions to confidentiality, please let me know. I will be happy to discuss this with you further.
For additional information regarding your confidentiality rights, please carefully review the attached HIPAA and Washington State Notice of Rights and Privacy Practices.
Insurance Providers
Insurance companies and other third-party payers may require that I provide them with information regarding the services I provide to you. This information may include the type of service provided, the dates and times of service, your diagnosis, treatment plan, a description of impairment, progress of therapy, and case notes and summaries. If you do not want me to provide your confidential information to your insurance company, let me know so that we can discuss alternatives.
Unless we agree otherwise, you will authorize your insurance company to send payments directly to me for services rendered and you accept full responsibly to pay all co-payments, deductibles, and balances due, and to promptly notify me if there is any change regarding your insurance coverage or your personal identifying information.
Group Family, Couples and Marriage Counseling
If you are seeking group, family, couples, or marriage counseling, it is important you understand that I will adhere to the ethical and legal requirements of confidentiality as stated above, however, I cannot ensure that you or the other participants in group, family, couples, or marriage counseling will maintain confidentiality about your therapeutic experience including content discussed within the counseling session. In addition, in the case of family, couple, or marriage counseling the entire treatment record will be available to any and all participants in the family, couples, or marriage counseling and all participants must consent to any authorized third party disclosure.
If you have any questions about the limitations to confidentiality, or about the access to treatment records, for group, family, couple or marriage therapy, please let me know. I will be happy to discuss this with you further.
Supervision and Consultation
I seek ongoing supervision and consultation from colleagues in order to provide you with the best services possible. I may disclose information about your counseling session in consultation with colleagues, in which case I will withhold your name and other easily identifiable information. I attend ongoing EMDR consultation with Katy Murray, LICSW, BCD. I have an agreement with Jeffrey Casebolt, LMHC to access my client files in order to make appropriate notification and referrals in case I am temporarily or permanently incapacitated. If you do not consent to Jeffrey Casebolt, LMHC accessing your file in case of my incapacity, please let me know so that I may make alternative arrangements.
Financial Requirements
Appointments: Therapy sessions are 50 minutes in duration. Please understand that when you make an appointment, I am reserving that time for you. If you are late, it may not be possible to extend your session for a full fifty minutes. I require 24 hour notice in the event that you need to cancel an appointment. If you do not show for a scheduled appointment, you will be charged a $65 fee. Insurance companies will not reimburse for missed appointments.
Group Therapy: If enrolled in group therapy, your presence in the group is expected at each session. Often there are waiting lists for group membership and it is imperative that a strong commitment to attendance is made.
Fees: Sessions are billed at the rate of $175 for the initial intake appointment and $110 per session for individual counseling, family and couples counseling.
Payment: Payment by cash,check or card is due at the beginning of each session. This includes intake appointments if an insurance authorization has not yet been received by me. You will be provided with a receipt for these payments and can seek reimbursement from your insurance company, as applicable.Please make checks payable to Jill Joanis LMHC. A twenty-five dollar ($25.00) charge will be made for checks that are returned for any reason. As all fees/copays are due at the time of service, there is an additional charge for past due accounts accumulated on a monthly basis at the rate of 2% per month (12% APR). If the outstanding balance (of 60 days or more) on an account exceeds $500.00, services will be suspended until payment arrangements are made. If regular payments are not made on the account (per the payment agreement) services will be suspended until the balance is paid in full. This business contracts collection services with Evergreen Professional Recoveries, Inc. located at 12100 NE 195th St, Suite 325, Bothell, WA 98011. Accounts which are delinquent and for which payment arrangements are not met will be referred to collections.
Sliding Scale: Due to the low reimbursement rates of some insurance plans, I am no longer able to offer sliding fee scale.
Insurance: If I am an in-network provider for your insurance program, I will file your claims as a courtesy to you. It is your responsibility to contact your insurance company to verify that they will cover services with me. If you need assistance in this process, I will gladly help. Deductibles and co-payments are due at the time of the service rendered. You may also choose to submit claims for therapy with your insurance program for an out-of network rate.
Electronic Communications and Social Media Policy
In the regular conduct of my practice, I may make use of a cellular phone, or other portable communication device, to communicate with clients. In such cases, I will limit the information I store in any portable communication device to the minimum necessary. Please be aware that such forms of communication do have inherent risks to client confidentiality. If you would prefer that I do not store you name and telephone number in a portable communication device, or if you would prefer that I do not communicate with you via cellular phone, please inform me so that we can make alternative arrangements.
In order to best protect your confidentiality, I typically will communicate with clients via email for the purposes of scheduling or canceling appointments only. If you need to communicate with me via email for any other purpose, please discuss that with me in person. Professional ethics standards do not permit me to communicate with clients via personal social media.
•Email, texts and phone calls which deal solely with schedule and/or billing issues will be responded to within one business day. If I am out of the office for training or vacation, I will provide this information and let you know when you can expect a response.
•If you are in crisis and need to speak with me, please call and leave a voicemail. I cannot respond to a crisis via text or email. Crisis intervention is short-term and focused on planning for next steps to keep you safe and create access to additional supports.
•Issues which are not related to scheduling/billing and do not require an immediate crisis response from me as your therapist can be noted in a journal or on a personal device and brought to our next session for discussion.
•If you wish to send me an email update on your goals or other information pertaining to your life, I will print it and place it in your clinical file. We can discuss it at your next session, if you wish. I am not able to provide email or text responses to these informational updates.
Emergencies
If you are experiencing an emergency or crisis, please call 911 or go to the nearest hospital Emergency Room.
State of Washington Disclosures
The State of Washington requires that I provide you with the following information:
You have the right both to receive appropriate care and treatment, and to refuse any treatment you do not want. You have the right to choose a counselor who best suits your needs and purposes. Counselors practicing counseling for a fee must be registered or licensed with the department of licensing for the protection of public health and safety. Credentialing of an individual with the department of Health does not include a recognition of any practice standards, nor necessarily imply the effectiveness of any treatment.
A copy of the acts of unprofessional conduct can be found in RCW 18.130.180. Complaints about unprofessional conduct can be made to:
Health Systems Quality Assurance Complaint Intake
Post Office Box 47857
Olympia, WA98504-7857
Phone: 360-236-4700
E-mail:
I maintain a referral list of other counselors with a wide range of specialties. I will provide you with a referral to another counselor if I feel your needs are beyond the scope of my expertise, or if you request such referral information.
Consent for Treatment
By signing this document, you are attesting that you have received, read, fully understand and consent to the disclosures, terms, and conditions above, that you have received a copy of your HIPAA and Washington State Notice of Rights and Privacy Practices, have read and fully understand these rights, and have been given the opportunity to ask questions.
By signing this document, you are attesting to your consent to participation in counseling services provided by Jill Joanis, MA, LMHC.
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Disclosure Statement and Agreement for Services
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Jill Joanis, MA, LMHC