KELLY J. NIESS MA
Licensed Marriage and Family Therapist
Grief Counselor
Individual, Couple and Family Therapy
INFORMED CONSENT, DISCLOSURE STATEMENT and OFFICE POLICIES
The following disclosure meets the requirements of Washington State Law. Please read thoroughly and ask any questions you may have.
“Counselors practicing counseling for a fee must be registered or licensed with the department of health for the protection of the public health and safety. Registration does not include a recognition of any practice standards nor necessarily implies effectiveness of any treatment. “ WAC 246-810-031
PROFESSIONAL QUALIFICATIONS
I hold a masters degree in Marriage and Family Therapy from Pacific Lutheran University. I am a Licensed Marriage and Family Therapist (# LF60123463) in the state of Washington and a clinical member of American Association of Marriage and Family Therapy and Washington Association of Marriage and Family Therapy.
In addition to my academic training, I have worked extensively with adolescents in school districts, mental health settings and a residential treatment program. I also specialize in couple therapy and working with individuals and families in dealing with issues such as depression, anxiety, relationship problems and lifespan transitional difficulties.
THERAPY ORIENTATION
I work from an integrated approach based on psychodynamic, cognitive behavioral and family systems theory. I pursue continuing education and will wholeheartedly use my training and experience to collaboratively help you meet your goals. It is my sincere hope that you feel honored, respected and hopeful after our encounter and that it carries over into your everyday life.
I will work with you to help you make the desired changes in your life, however I cannot promise anything about the results you will obtain. Your outcome will depend on many things.
CLIENT RIGHTS and CONFIDENTIALITY
I will hold all information confidential unless you grant permission for me to share information using a Release of Information Form. However, Washington state law RCW 18.19.180 (1) requires that confidentiality must be breached when 1) abuse of a child or elder is reported or suspected, 2) I believe there is imminent harm to yourself or another, 3) a court order has been issued by a judge.
I do consult with colleagues regarding my work with clients to gain feedback and suggestions for treatment. My work with you might be discussed, however your privacy will always be protected. All discussions of this type are subject to the same provisions of confidentiality as discussed above.
You have the right to terminate treatment at any time. You are entitled to be treated with dignity and respect. You have the right to be free from being the object of discrimination based on race, religion, gender or other unlawful category while receiving services.
SCHEDULING AND FEES
You and I will schedule appointments directly. Sessions are 45-50 minutes long. If you must cancel a scheduled appointment, please let me know as soon as possible. If you miss a scheduled appointment, and are unable to cancel at least 24 hours ahead of time, you will be charged $100.00 for the missed appointment. Unfortunately, your insurance company does not pay claims for missed visits, so you will have to pay that fee yourself before the next session.
I currently participate in some health plans as an out of network provider, and as a preferred provider for others. Please contact your insurance company to understand your mental health benefits. Some companies require preauthorization for mental health services. Some plans do not cover relationship counseling. If charges are denied by a health plan, they become your responsibility, even if you understood from your health plan that the charges would be paid by them. I will provide you a statement of services rendered and paid for by you to submit to your insurance company upon request.
By your signature below, you authorize me to provide your insurance and managed care providers with any information necessary to file and to process your claim for payment and approval.
LITIGATION
I do not, nor will not, participate in legal actions for the purposes of child custody and/or divorce proceedings. This includes testimony and/or release of records for purpose of such legal action in accordance with state law.
If any party of this agreement, and/or their representative, takes action to involve me in legal actions, the initiating party, and/or their representative, agree to pay the following fees, for each individual and/or separate action such as, but not limited to, testimony, depositions, declarations, written and/or oral reports.
- Any and all travel related expenses
- A litigation fee of $1500.00
- Any and all fees for the purpose of representation for myself
Failure to pay fees, by any signing party and/or their representative, in full and in advance of such action will constitute an outstanding balance.
If legal action is taken against me, I will utilize any and/or all resources, to include a counter suit, to defend and/or protect my assets, under the law. This may include disclosure of confidential information in accordance with state and federal law.
CRISIS
I do not provide crisis services. If you are in crisis and are in need of services, you, the client, agree to call 911.
By signing below you indicate that you have read the above material, agreed to its terms and have had the opportunity to ask questions.
CLIENT CONSENT TO USE ELECTRONIC MAIL (E-MAIL) AS A FORM OF COMMUNICATION
Initial on the line below if you permit the use of email as an acceptable form of communication. If you would like to receive email confirmation for upcoming appointments, please provide your email address. Please note that email may not be a secure form of communication and you may be compromising your confidentiality by using it to communicate with me.
Initial and Date Email Address:
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Consent For Treatment
I/We have read the above Notice of Privacy Practices & Disclosure Statement. I/We agree with the terms listed herein on all pages and consent to treatment. (All family members 13 years and older must sign the consent.)
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Signature Printed name Date
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Signature Printed name Date
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Kelly J Niess MA LMFT Date