A/M Clinical Services, PLLC
715 S. Lane St., Suite A l Seattle, WA 98104
206.886.2627 l email@amcspllc.com
www.amclinicalservices.com
NOTICE OF PRIVACY PRACTICES AND DISCLOSURE STATEMENT
This disclosure is between your person, individual &/or self (hereinafter referred to as the “Client” or “Patient”and also as “you” or “your”) and A/M Clinical Services (hereinafter referred to as the “Counselor,” “Therapist,” or “Provider” and also as “I,” or “my.”)
Welcome to my private practice.
This document contains important information about my professional services and business policies. Social Worker Independent Clinical Associates are required by state law to provide information about their practices to prospective clients.
Please read this carefully and let me know if you have any questions or concerns. You will be asked to acknowledge and agree to the information enclosed and then physically sign the same document at our first session. When you sign this document, it will represent an agreement between us. You are not liable for any fees or charges for services rendered prior to the receipt of this disclosure statement.
Professional Training and Therapeutic Orientation
I am a Licensed Social Worker Associate Independent Clinical in Washington State, License number SC61072800. I graduated from the University of Washington School of Social Work in 2019, and completed the state’s licensure requirements to become an LSWAIC. I have a passion for working with the LGBTQI2+ and POC communities, with emphasis on Trans* Asian Pacific Islanders and have experience with these populations in public and clinical settings since 2000; since 2003 I have been working primarily with the LGBTQI2+ communities in the health and social services fields. Professionally and ethically, I am continuously seeking trainings that will enhance my therapeutic skills that provide positive impact with you.
I provide individual therapy and group therapy; my goal is working with my clients to create a unique treatment plan that fits their values and desires to positively change their life. I believe that reaching out for help is not a sign of weakness, but rather a sign of strength. You have recognized that something doesn't feel right and you want a better life for yourself. Therapy is a safe place to explore your current challenges and stressors, learn about the connections between your past and present, and actively take steps towards achieving your goals. I began clinical work with the goal of expanding from my background in addictions counseling with the LGBTQI2+ communities, I developed a specialty in harm reduction and recognizing addiction as part of behavioral health.
I believe therapy is a collaborative process and I work with clients to create a plan that fits their values and goals – I do not and cannot make decisions for you or tell you how to handle a situation or define right and wrong for you. If you are coming to therapy for a specific goal or skill-building, we can work together to explore your emotional experience, brainstorm different options, make plans and practice accountability for your decisions. Our work together can also be an exploration into who you are and how you came to be the person you are today, processing past or recent hurt or trauma. Studies show that the greatest contributor to successful treatment is the positive relationship between the therapist and client. I work hard to collaborate in a supportive environment for all the clients I work with.
As a social worker, I have been trained to incorporate who you are as an individual with the environment in which you live, work, and interact daily. Therapy is not an easy process – remembering or talking about unpleasant experiences can result in feelings of anger, sadness, worry, frustration, or loneliness. Sometimes we are working together to change habits that have been automatic for decades. Together, in a safe environment, I believe each client can create the changes they desire in their life. I use a variety of therapeutic modalities such as, but not limited to, cognitive behavioral therapy (CBT), interpersonal therapy, solutions-based therapy and processing grief and loss.
Risks and Benefits to Therapy
Psychotherapy or therapy is a personal process and the experience is different for each client. There is no guarantee that therapy will work the way you want it to and solve situations for you. Therapy often brings up difficult memories or emotions that persist even after our session has ended; progress may be slower than originally expected or predicted. Much of the work we do in session will require time and effort processing or practicing skills outside of session and success depends on your ability to follow through. I do not provide medication, prescription recommendations, or legal advice as these activities do not fall within my scope of practice. Despite these limitations and risks, therapy can help in many ways. Committing to treatment often results in developing new and empowering coping skills, positive behavioral changes, a reduction in symptoms that interfere with quality of life, and the ability to address future problems and stressors with an increased sense of self and confidence. Washington State Law requires you to know that counselors practicing counseling for a fee must be registered or licensed with the Department of Health for the protection of the public’s health and safety. Registration of an individual with the department does not include recognition of any practice standards, nor necessarily implies the effectiveness of any treatment.
Confidentiality
It is important for you to know that I am involved in multiple projects and organizations, in addition to the services I provide at Aleks Martin Clinical Services, PLLC. I work at Public Health - Seattle & King County with various departments, and primarily with HIV research. I completed my work as a advanced social work practicum internship at Hepatitis Education Project in May 2019 and remain connected with the organization. I also often take other facilitation roles with organizations within the Seattle and King County area. In my capacity as an individual therapist, I follow a strict conflict of interest and confidentiality policy. Your information will not be shared between roles and companies. Please feel free to address any concerns or conflicts with me at any time. You have the right to Confidentiality in our work together as provided in RCW 18.19.180. Information revealed by you during your therapy is confidential, and will not be shared with anyone else without your written permission, except where disclosure is required by law or as provided below:
You give written consent, or in the case of the death or disability of the client, the client’s personal representative, other person authorized to sue, or the beneficiary of an insurance policy on your life, health or physical condition gives written consent.
If the client is a minor, and the information acquired by the counselor indicates that the minor was the victim or subject of a crime, then the counselor may testify at any proceeding wherein the commission of the crime is the subject of the inquiry.
If you bring charges against me with the State of Washington Department of Health, the records will be released to the Department of Health.
The event of such disclosure will avoid or minimize an imminent danger to your health or safety.
In response to a subpoena from a court of law or the secretary of the Department of Health. The Secretary may subpoena such records if they are related to a complaint or report under RCW 18.130.
If the records are subpoenaed by an attorney in the State of Washington, provided such compulsory process was in accordance with RCW 70.02.060, they will be released unless you procure a Protection Order within fourteen days of the date of the subpoena was served on the counselor and on you.
If it becomes necessary to refer your account for collections or to legal counsel in order to collect amounts owed by you (this would not include any information other than the fact of money owed for services by you).
As required by RCW 26.44 as now or hereafter amended, (Abuse of Children and Adult Dependent Person) which requires reporting to the proper authorities in all cases of suspected abuse (or victimization by a crime) including sexual exploitation, negligent treatment or maltreatment, abuse or neglect of a minor, a developmentally disabled person or an elderly adult.
I may consult with another professional about your concerns and how I might proceed in order to help you, but I will do so without using your name. The other professional will be bound by the rules of confidentiality as well.
Most insurance companies require a diagnosis and some require progress reports. If your insurance company covers my services, you may want to check out their requirements before billing them, as these reports represent a leak in your confidentiality.
In the event of sudden death or incapacitation, my professional will dictates that a designated Professional Executor, who is also a mental health clinician, will take control of all records and client contacts for the purpose of notification and assisting re-establishing with a new provider as desired.
I am compliant with the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and client’s rights with regards to personal health care information.
My professional records are separately maintained and no other individual can have access to them without your specific, written permission. Client files are confidential, are retained for a period of seven years following our last completed session, and destroyed after the seven-year period (WAC 246-809-035). If you would like me to have communication with others as it relates to your therapy, you will be required to sign and date a written permission for Release of Information (ROI) to any individual(s) of your choosing. Since the nature of therapy is to provide a safe environment to work on personal issues, it is recommended that this information be released only to those individuals acting on your behalf.
I am often out and about in Seattle and surrounding areas. To protect your confidentiality, if I see you in public I will not initiate contact with you. If you initiate contact with me, I will respond accordingly, but not further than is offered. This is to protect your own confidentiality and the integrity of our work together.
Business Practices: Expectations, Attendance, and Billing
Therapy treatment and progress relies on regular sessions; I prefer to meet with clients weekly for the first 1-2 months before re-evaluating with you if changing the frequency of our appointments is in your best interest. I also realize that weekly appointments can be more stressful than supportive; we will discuss and determine the initial schedule together. Although I will outline a general timeline at the beginning of our work, therapy is a very individual process and that timeline may change at any time, based on your preferences or my recommendations. While I do see clients for long-term work, most of my clients are coming to therapy with a specific goal in mind and once those goals are met and stability is found, they prefer to end our work together (averaging 3-6 months). I am here to support you and we will periodically check in together about how you are feeling about your progress and how we will navigate your treatment plan together. As part of this, it is important that you keep your scheduled appointments. Some clients prefer monthly appointments for maintenance work; this must be agreed upon together. Please note that spacing out appointments longer than 1 month apart is not clinically recommended. If you have not been seen for 6-8 weeks without prior arrangement or agreement I will contact you regarding scheduling; I will offer a final chance for scheduling as well as a tentative date for terminating our services. Without communication or scheduling, our treatment will be considered complete and you will no longer be under my care. Unless otherwise communicated, you can return at any time, but will need to re-establish care for any future appointments. Preference for scheduling will be given first to current clients, then former clients looking to return, and finally new clients looking to establish care.
Therapy sessions are by appointment only. It is important to know that my building is a smoke-free and weapon-free zone; violations of this policy may result in termination of care for our safety and the safety of others.
I am not in-network with insurance companies at this time, but I can provide you with a superbill (an itemized list of services) to verify services for insurance reimbursement or out-of-network coverage benefits.
All sessions are 50 minutes unless otherwise arranged. My fee is $120 for individual sessions. I have limited sliding scale spots available for clients with a financial need; please discuss this with me prior to our first appointment. Proof of financial need is required to qualify for a sliding scale rate.
You are responsible for the session fee at the beginning of each appointment. Fees can be paid via Simple Practice.
With SimplePractice's client portal, clients can fill out intakes, request appointments, send messages, pay bills, and more, from a secure client portal.
If you cancel with less than 24 hours notice, you will be charged the full amount. If you do not show up to the appointment without notification, you will be billed for the full cost of the appointment. You will be responsible for the full fee. The only exceptions to this rule are if you would endanger yourself by attempting to come (for instance, driving on icy roads without proper tires) or if you or someone for whom you are a primary caregiver has fallen ill suddenly. If you are late for a session, I may see you for the remainder of the original time scheduled; if you are more than 20 minutes late, you may have to reschedule your appointment. If tardiness or attendance becomes an issue, I will address my concerns with you directly and offer referrals for other providers who may be a better fit for you.
I will communicate all scheduled office closures and absences with as much notice as possible and communicate with you in session as events come up; where needed, I will accommodate changes in our scheduling pattern so that I can continue to meet your therapeutic needs. While I try to minimize any unplanned time off, it does happen and I ask for your patience and understanding. I will try to communicate with as much notice as possible with unexpected absences. If I need to take a longer leave of absence, I will coordinate with other providers in the area for continuation of care during my absence, either for phone check-ins as needed or scheduled appointments, in an attempt to minimize disruptions to your treatment. I make every effort to keep insurance coverage in mind in these circumstances but cannot guarantee I can find a temporary provider in the area who takes your insurance and/or who matches my fees. It is ultimately your responsibility to determine any new or different fees with another provider. I will notify you when I am ready to start scheduling clients and you are welcome to return unless otherwise communicated.
You have the right to review your records and files at any time. You should know that for your protection I keep very minimal records: billing information, correspondence, release forms (if any) and my copy of your signature page assuring that you have read this document and been informed of the way I counsel, my competence and your rights. I include a few notes, but I usually share my understanding of your concerns directly with you. When you sign the Signature page to this Disclosure Statement you will acknowledge that you want me to keep minimal records. Requests for records, either by yourself or a third party, can only be released after receiving a signed Release of Information or ROI by the client/legal guardian. There may be a small fee for records requests in order to cover copying/printing, postage if necessary, etc. Fees will be discussed and acknowledged prior to completion of the records request.
Communication and Social Media Policies
Psychotherapy is one of the most private endeavors in which anyone can engage. We will be sharing your personal thoughts and feelings in a way that is different from social and intimate relationships outside of therapy. The success of this work depends in part on maintaining the privacy of what we discuss together. Our therapeutic relationship prevents our ability to have a social or intimate relationship outside of the office, to promote our work as a personal endeavor. To protect the private nature of our work and keep it separate from our lives outside of our work, I encourage you to not post any information about our work online or in social media outlets. I will do the same, unless required by law or requested by you to break confidentiality, though I do not automatically share information about your treatment unless we agree that it is necessary. I will discuss any information about our work that I share with others first with you.
I do not communicate nor interact with clients on my personal social media accounts, it is your choice to follow any business social media accounts related to A/M Clinical Services. Our work together will never be disclosed on any of these social media platforms. I do not accept friend or contact requests from current or former clients on any of my personal social networking sites (Facebook, Twitter, Instagram, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise confidentiality and respective privacy. If you have questions about this, please bring them up when we meet and we can talk more about it. I may keep a professional and business social media presence for my professional practice to allow people to share appropriate posts and updates with other social media users.
Please note that I will not follow you on social media. I do not follow current or former clients on any social media accounts, both personal and professional. In addition, viewing your online activities without your consent and without our explicit arrangement towards a specific purpose could potentially have a negative influence on our therapeutic relationship. If there are things from your online life that you wish to share with me, please bring them into our sessions where we can view and explore them together, during therapy.
The state requires that I have your physical signature on file prior to beginning our work together and at that time, you will also have the ability to accept or decline various communication options. I ask that you consider your choices carefully and choose the options that fit best for you. None of your choices will negatively impact the work we do together, but it is important to advocate for your own wants and needs. These preferences can be updated at any time, and I ask that all clients renew the disclosure statement and review their communication preferences at the beginning of every calendar year. Ideally, all communication between us occurs in person at our sessions. When it is necessary to communicate between sessions, I ask that you call me at 206.886.2627 so we can arrange a phone conversation. If I need to contact you, I will call the phone number you provide me. I do not communicate on social media sites with clients to protect the privacy of our relationship. I do not communicate with clients by email or text, unless you have consented to receive communication by those methods knowing the risks and limitations – and if we do communicate electronically, I will keep my side of the conversation short and brief to protect your privacy.
Again, you may reach me at 206.886.2627, which includes a confidential voicemail. I make every effort to return messages in 24-48 hours. I check my messages and email a few times during the daytime only, unless I am away from my office for an extended period of time. You will be informed in advance of this schedule change. If there is a life-threatening emergency, please call 9-1-1 or for after-hours and if it is a non life-threatening emergency, please call the 24-Hour King County Crisis Line at 866.427.4747. Please do not use emails or texts for emergencies. If we decide together that you need a provider who can be available to you more frequently or provide care that I am not able to provide, I will assist you with additional referrals.
In the technological world that we live, I make every effort to ensure the treatment you are receiving is confidential. Depending on the method of communication and provider, there is always the possibility that unauthorized persons may attempt to discover your personal information. I take every precaution to protect your information but cannot guarantee unauthorized access to electronic communications (including but not limited to telephone/voicemail, email, secure patient portals, and text). Voice mail and phone calls are more secure methods of communication than email or text. Be aware that emails can be read by third parties and that if you use your work email your employer can intercept or if friends, family, significant others, or coworkers share access to your computer or phones. If you choose to communicate with me by email, be aware that all emails are retained in the logs of your and my Internet service providers; the same can be true for text communication depending on the provider and plan. You should also know that any emails or texts I receive from you and my response that I send to you can become part of your legal record. Some clients prefer the convenience of email communication and texting despite their lack of security. I ask that you determine your own preference for security versus convenience in communication.
You may find information about my practice at my website. If you do come across personal or professional information about me online or through other people, I encourage you to bring it up in our discussions, as you feel necessary and/or critical in our therapeutic relationship. I will not seek information about you online or through others but will bring up any information that I inadvertently come across about you. If I need to collaborate with other health care professionals about our work as part of my legal responsibilities, I will discuss what I communicate before doing so and have you sign a Release of Information form.
Professional Standards
Successful therapy requires the effort of both the therapist and the client. You have the right to refuse therapy services and a responsibility to choose a therapist who best suits your needs. I am a member of the National Association of Social Workers (NASW) and I am accountable for my work with you and agree to provide services to you in an ethical and professionally competent manner. After the first 2-3 sessions, I will assess if I can be of benefit to you. I do not accept clients who, in my opinion, I cannot help. In such a case, I will give you a number of referrals who you can contact. If at any point during psychotherapy I assess that I am not effective in helping you reach your therapeutic goals, I am obligated to discuss this with you and, if appropriate, to terminate treatment. In such a case, I would give you referrals that may help you establish with a new provider.
You have the right to discuss with me any questions you have about your therapy. You also have the right at any time, and for any reason, to decide that you do not wish to continue therapy or to change therapists. I will provide names of other therapists in the area as well. I encourage you to discuss your decision to end treatment, as it is an important part of the therapeutic process.
If you have any concerns &/or complaints you can contact the Association of Social Work Boards (800) 225-6880 or Washington State Department of Health (800) 525-0127 (The Department of Health, Health Professions Quality and Assurance Division, PO Box 47869, Olympia, WA 98504-7869).