1603 116th Ave. NE, Suite 114, Bellevue, WA 98004

(425) 646-2778 x. 3

Tom Freeman, MA, LMFT

Psychotherapy Information Disclosure Statement

Washington State Credential No.: LF 60208478

Washington State Tax ID Number: 602-332-853

AAMFT No.: 117503

Welcome. Before you agree to enter into the therapeutic process, Washington State law requires the transmission of information contained within this disclosure statement. This information will assist you in giving what is called “informed consent,” which means that you have adequate understanding of the therapeutic process and that you can make a reasonably informed decision as to what services you will receive.

“Psychotherapy,” “therapy,” and “counseling” all speak of the process wherein an individual seeks to understand feelings and behaviors. At its best, this process can liberate an individual from patterns that are considered by the individual to be limiting, unhealthy and/or painful. There are many types of psychotherapy available and it is practiced by a wide variety of practitioners, including psychiatrists, psychologists, nurses, social workers, and school counselors. There are also many types of psychotherapy available such as psychoanalysis, cognitive-behavioral, personal construct, psychodrama, narrative, somatic, etc. My personal approach is described below.

My Background

I am a psychotherapist who works with individuals, couples, families, and groups. I hold a Masters Degree in Clinical Psychology from Antioch University Seattle. I have served as the Director of Programs for an agency providing grief support services to children and adults, where I coordinated adult, teen and children’s programs, served as liaison to area schools, facilitated grief groups, and provided individual counseling. I am a certified practitioner of Parent-Child Interaction Therapy (PCIT) and Lifespan Integration (LI) and I have trained extensively in utilizing Clinical Hypnosis and Mindfulness-Based Stress Reduction. I currently serve on advisory committees for Get Your [Stuff] Together and Art with Heart and I also function as a Clinical Research Associate on a joint study between Seattle Children's Hospital and the University of Washington, examining treatment modalities with suicidal teenagers. I maintain memberships within the American Society of Clinical Hypnosis (ASCH) and the American Association of Marriage and Family Therapists (AAMFT).

How I Work

I have been trained within a systemic framework that holds that all things are connected and that nothing can be understood on its own – all things must be understood as components of larger organizations. Relatedly, all things are constantly shaping and being shaped by a larger context (familial, social, political, etc.). In relation to families, the functioning of every family member has some effect on the functioning of the whole family, and the functioning of the family as a whole has some effect on the functioning of every individual.

My theoretical orientation is primarily aligned with the Cognitive / Behavioral Therapy model that posits that the way we perceive situations influences how we feel emotionally. This emphasizes the need for attitude change to promote and maintain behavioral modification. As such, much of my work focuses upon responsive thoughts and identifying distorted thinking, modifying beliefs, relating to others in different ways, and changing behaviors.

In my practice, the object of therapy is to help an individual relinquish dysfunctional defenses and replace an other-validated sense of self with self-awareness and self-validation. To this end, I employ a variety of approaches, sometimes singularly, sometimes simultaneously. These approaches include, but are not limited to, the examination of the ways in which we characterize people and situations, examining the language we use to recount experiences, the consideration of reframing situations and feelings, the reading of books, the maintenance of a personal diary, and meditation.

I generally spend our initial sessions listening to your history and your past and current relationships, and asking questions. This helps me make a good assessment of your needs. After the assessment, I’ll write up a treatment plan with you that will indicate what we will be working on, how we will be spending our time, and how we will know we are making progress. If you agree to enter into therapy with me, we will meet in my office for regular 45- or 60-minute sessions. At some point during the therapeutic process, you may wish to invite another person to join us. You are welcome to do so, but I require that such an invitation be extended only after we have had an opportunity to discuss the intent behind this invitation.

Fees

The fee for appointments is based on 50 minute sessions. I charge $175.00 for the initial session, and then my standard fee is $150.00 per one hour session or $135.00 for a 45 minute session. If your insurance plan has a co-pay, please be aware that it is due and payable at the time of service, and please be prepared to pay it. If you are an EAP client, the guidelines of your EAP program supersede the fee schedule outlined above.

Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hour notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, late cancellations (less than 24 hours’ notice) or “no-shows” will be charged the full fee of the session scheduled. Most insurance companies do not reimburse for missed sessions.

In the event of snow, ice, or other extreme weather condition, I go by the Bellevue School District’s decision as to whether or not I will come into the office. I do offer Skype as an alternative meeting method if you wish to keep your appointment, but, I do not charge for late cancellations due to extreme weather conditions.

I am in-network with a number of insurance providers. If I am not paneled with your insurance provider, your counseling services may still be eligible for reimbursement through out-of-network benefits, medical spending or health care savings accounts. Health insurance plans and benefits vary; check with your provider about reimbursement for your counseling services. As a courtesy, I will bill your insurance company directly. Alternately, I can assist you by providing statements of services and fees that you can submit directly. Either way, be aware that when you enter into this agreement, you accept responsibility for paying the agreed-upon fee and co-pay at the end of each session whether or not your insurance company reimburses you.

There are individuals who make a conscious choice not to utilize existing healthcare coverage for mental health services. There are a number of reasons that support making this decision:

1.  Your therapy is not limited by the diagnoses or treatment plans that are required by health insurance companies. (These companies control the number of sessions, session frequency and even the type of therapy allowed.)

2.  The required mental health diagnosis becomes a part of your permanent health care record.

3.  In addition to the required mental health diagnosis, insurance companies have the right to obtain a great deal of additional information about you before granting coverage. The insurance company can review all of your records at their discretion.

4.  Many insurance plans do not cover couples, relational and/or family therapy.

5.  Most insurance companies require a deductible to be met before benefits are provided, leaving you to pay out-of-pocket regardless.

Clients who choose to pay privately or out of pocket secure for themselves the highest degree of privacy, flexibility and control of their mental health records allowed by Washington State law, since these records are exempt from insurance reporting and random compliance audits. In essence, this choice allows you to remain “off record” and maintain control.

Payment

Payment is made at the end of each session. OptimalLife accepts checks, cash, or Visa/ Mastercard / Discover/American Express for payment. There is a $30.00 fee for returned checks. If you are utilizing insurance, it is your responsibility to ensure that your particular plan covers the services we provide.

Telephone conversations, site visits, report writing and reading, email writing and reading, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify me if any problems arise during the course of therapy regarding your ability to make timely payments. Furthermore, not all issues, conditions, and/or problems addressed in psychotherapy are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. If your account is overdue (unpaid) and there is no written agreement on a payment plan, I may use legal means (courts, collection agencies, etc.) to obtain payment.

Appointments and Cancellations

I believe that consistency in therapy is important to growth and I ask that you observe your appointment and arrive on-time. However, I understand that a conflict may occur and you (or I) may need to reschedule an appointment. If so, a minimum of 24 hours of advance notice is required for canceling or re-scheduling an appointment. Unless we reach a different agreement, the full fee of the session scheduled will be charged for sessions missed without such notification. (Please note that insurance companies do not reimburse for missed sessions; this cost will be billed directly to you.)

Should you need to cancel, reschedule and/or communicate with me between sessions, you are welcome to either e-mail me () or call and leave a message at (425)-646-2778, x. 3. I will respond as soon as possible.

In the event of extreme weather conditions, OptimalLife Wellness Center adheres to the Bellevue School District’s decision on school closures and will contact you via phone or email to inform you of office closure.

Confidentiality

With the exception of certain specific circumstances outlined below, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me, without your prior written permission. Your file, along with any information exchange we have outside of our regularly scheduled appointments (voice mail, e-mail), is secure and is accessible only by me.

You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law insures the confidentiality of all transmission of information about you, whether verbal, written, electronic, or otherwise.

Your Rights and Responsibilities as a Client

By law, you as a consumer of mental health services have the right to:

  1. Be treated with respect and dignity at all times;
  2. Develop a plan of care and services which meets your unique needs;

3.  Refuse any proposed treatment;

4.  Suggest a proposed treatment;

  1. Review and/or copy your file;
  2. Discontinue treatment at any time;

7.  Confidentiality, as provided by laws which state that I cannot disclose any information you have told them either during a counseling session or through any other means, unless:

a.  you provide written consent;

  1. the information concerns certain crimes or harm (inflicted or imminent) to self or others;
  2. I have reason to believe that a child or dependent adult or developmentally disabled person has suffered abuse or neglect;
  3. I am required by court order or proceedings to do so; and/or
  4. It is required by insurance providers.

At certain times, it may be to your benefit for me to consult with a colleague or specialist about your issues. I will not share any information which would identify you. Additionally, I do not keep individual confidences when working with a family or couple.

You are charged with the responsibility to:

1.  Safeguard your health and respect your unique presence in the world;

2.  Treat me with respect at all times;

3.  Respect our time together as important in your personal growth;

4.  Provide payment for my services as they are received and/or ensure that your particular insurance plan covers the cost of your treatment.

My Rights and Responsibilities as a Therapist

I have the right to:

  1. Be treated with respect and dignity at all times;
  2. Develop a plan of care and services which I feel meets your unique needs;
  3. Restrict access to our time together by any other individual(s);
  4. Discontinue treatment at any time should I feel that I am not able to meet your therapeutic needs or that the continuance of therapy would no longer be in your best interest or mine.

I have the responsibility to:

1.  Treat you with respect at all times;

2.  Provide you with the best possible care to the best of my ability;

3.  Operate fully within the laws of the State of Washington and the ethical code of the American Psychiatric Association;

4.  Discontinue treatment should I feel that I am not able to meet your therapeutic needs.

Termination

After the first couple of 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 therapy I assess that I am not effective in helping you reach your therapeutic goals, I am obligated to discuss it with you and, if appropriate, to terminate treatment. In such a case, I would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, I will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want the opinion of another mental health professional or wish to consult with another therapist, I will assist you in finding someone qualified, and if I have your written consent, I will provide her or him with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, I will offer to provide you with names of other qualified professionals whose services you might prefer.

Department of Health Statement

The State of Washington requires that I inform you of the following:

“Counselors practicing counseling for a fee must be registered or licensed with the Department of Licensing for the protection of public 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. The purpose of The Counselor Credentialing Act is to provide protection for the public health and safety, and to empower the citizens of the State of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct.”