RAINIER ASSOCIATES

5909 Orchard West

Tacoma, Washington 98467

Ph. 253-475-6021 Fax 253-474-1871

www.rainierassociates.com

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CLINICAL ASSOCIATES

J. Dale Howard, M.D. / Emily Schoenfelder, M.S.W. / George Jackson, M.D.
Barry S. Anton, Ph.D., ABPP / Naomi Huddlestone, Ph.D. / Catherine A.J. Mulhall, M.S.W.
Fletcher B. Taylor, M.D. / Ryan Coon, PSY.D
Trenton J. Williams, Ph.D. / Jodi Howell Nagy, Ph.D.
Susan J. Poole, Ph.D.
Vanessa Honn, Ph.D. / Amy Dwyer, M.S.W., LICSW
E. Thomas Dowd, Ph.D., ABPP
Stephanie Munizza, MA,LMFT

Stephanie Munizza, MA, LMFT, CDP

Washington State law requires that I provide you with the following information, and that you indicate you have been informed by signing a copy of this form. The purpose of this disclosure statement is to give information about me, information about your rights and responsibilities, and information about what you can reasonably expect from our therapy work together, so please read all of the information carefully. The foundation of successful therapy is a solid working relationship between client and therapist. If our work together is not meeting your needs, please feel free to discuss your concerns so we can make appropriate changes. I will assist you in finding another therapist if I am not able to address your concerns. You have a right to take a break, discontinue, or refuse treatment at any time. I welcome questions and feedback about our work together at any point throughout our process.

Credentials: I am licensed in the State of Washington as a Marriage and Family Therapist (LMFT) and as a Chemical Dependency Professional (CDP). My credential numbers are LF60521654 and CP60312423. I received a Master’s of Arts Degree in Counseling Psychology from St. Martin’s University in 2010 and a Bachelor’s of Science Degree in Psychology from St. Joseph’s college in 2005.

Theoretical Orientation and Practice: My training incorporates various counseling approaches, such as Family Systems, Cognitive-Behavioral Therapy (CBT), Humanistic and Experimental theories. I prefer using EMDR, an evidence based therapy for the treatment of trauma, in my work with individuals. I have experience in working with such issues as depression, anxiety, grief and loss, drug and alcohol abuse or dependency, emotional, physical, sexual neglect or abuse, as well as a variety of other life issues.

Current Practice: I work with individuals, couples, and families. Regardless if you are coming to therapy on your own, with a partner, or your family, I will tailor the therapeutic process to fit your needs. I believe that therapy is about gaining awareness and understanding, and once that is accomplished, there is a choice to make a change or not. I also believe that you are the expert of your mind, emotions, body, and spirit, and my role involves navigating, challenging, mirroring, and supporting you on your path.

Confidentiality: Information discussed in therapy is confidential. I will not release any information without your written permission, apart from the following exceptions as required by law: I may be authorized or required to disclose information you provide to me if I suspect there has been child or elder neglect and/or abuse or if you are a threat of harm to yourself or others. If you are filing an insurance claim, information regarding your dates of service, diagnosis and treatment plans may be released to your insurance company. Your name and identifying characteristics will not be disclosed if at any time I consult with professional colleagues about general aspects of your case.

Appointments: Making and keeping appointments is important to the therapeutic process. Appointments begin at our agreed upon time, not when you arrive. Your appointment is held exclusively for you. It is important to be on time because your appointment time cannot be extended beyond the scheduled time since other people may have reserved that time. 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 for the missed session. Insurance does not reimburse for missed appointments.

Emergency Calls: Please do not leave emergency messages on my personal voicemail, as I cannot assure I will retrieve messages after hours or on weekends. When you call the Rainier Associates main number (253-475-6021) an answering service takes all emergency calls outside of regular business hours. They will attempt to locate me in the event of an emergency or will contact the on-call therapist covering for me. If you are experiencing a crisis and need to speak to someone immediately then please call one of the following:

·  Pierce County Crisis Line at (800) 576-7764

·  SuicidePreventionLifeline.org 1 (800) 273-TALK or 1 (800) 273-8255

·  911 or go to the nearest emergency room.

Billing and Payments: Please remember that fee payment is your responsibility. I request that you keep current with your portion of the bill (the part not covered by insurance) each session or at the end of the month. If you are unable to manage this, please work out a payment arrangement 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% may be added to any balance not paid in 60 days after the charge is incurred. If 90 days passes without a payment, accounts may be sent to a collection agency. If you have questions about your account you may speak to me or someone in the billing office at any time.

Insurance: I am a contracted provider for many, but not all local insurance companies. You should be sure to check with your insurance company and our intake office to learn whether I am a provider for

your plan. You should also inquire if your plan requires a preauthorization or a PCP referral, if you have a separate annual deductible for mental health and whether your mental health benefit has a maximum yearly number of sessions or a maximum yearly dollar amount. Our intake department can assist you with any of these questions.

The 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 attached to this office policy statement, you will also need to provide a copy of your insurance card.

Ending Psychotherapy: An expected goal of treatment is to end therapy. If you choose to end therapy prior to achieving your goals, I recommend you consider participating in a closure session which enables us to say goodbye.

Changes to Office Policy: From time to time there may be changes to the business policies described in this document. I will attempt to inform you of any relevant changes.

Consent for Treatment: I have read Stephanie Munizza’s Office Policy Statement and understand it. I consent to therapy under the terms described above and understand I have the right to terminate treatment at any time. My signature below indicates I have received a copy of this agreement.

Please print you name______

Please sign your name______

Today’s Date______

Stephanie Munizza, MA, LMFT, CDP

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