Asha Simpson Psychotherapy, PLLC

Address: 8011 118th Ave NE Kirkland, WA 98033 Phone: 425-999-9344

Licensed Independent Clinical Social Worker LW60282657

DISCLOSURE STATEMENT AND PERMISSION TO PROVIDE TREATMENT

Disclosure Statement

This is a statement of your rights and responsibilities for our therapeutic relationship. The RCW 18.19.060 and WAC 246‐810‐031 require counselors to provide written disclosure of the following information to clients before counseling begins. Therapist practicing counseling for a fee must be licensed with the State of Washington Department of Health, for the protection and safety of the public. I am in the State of Washington as a Licensed Independent Clinical Social Worker (LICSW) LW 60282657. This license is available to therapists who have a Masters in Social Work and are sufficiently experienced and trained in Clinical Therapy having passed the National Association of Social Workers Clinical exam.

As a Licensed Independent Clinical Social Worker in the State of Washington, I am providing the following disclosure of information so you can be fully informed about Asha Simpson Psychotherapy, PLLC. Please do not hesitate to ask me any questions or concerns that you may have. I intend to provide ethical, quality service in a professional manner. If as a client you have a complaint, you are encouraged to express your complaint with me. You may obtain a copy of the acts of unprofessional conduct listed under RCW 18.130.180. If you have specific questions for the State of Washington, either about me as a Licensed Independent Clinical Social Worker or about the counseling/mental health profession in general, please contact them directly. On line at: http://slc.leg.wa.gov or by mail at: Department of Heath Business and Professional Administration P.O. Box 9012 Olympia, WA 98504-8001 (360) 753-1761

Client Rights

You are encouraged to ask questions and gather information to help you make an informed decision. You are entitled to see, copy and correct factual errors in records kept regarding health care provided to you. All requests should be put in writing and a fee will be charged to copy your records. If at any time you are uncomfortable with the direction the counseling is taking you have the right to discuss this with me so that we can make adjustments. This might include a change of the counseling approach, a referral to another counselor, or discontinuing counseling.

Qualifications

I earned a Masters Degree in Social Work from the University of Southern California in 2008. I earned a Bachelor of Arts Degree from Seattle University in Sociology with Minors in Social Work and Philosophy. I have worked in a variety of therapeutic settings including private settings, non-profit, for profit medical settings and public schools. Although, I address a broad range of mental health issues in my practice, I have specific interest and training in attachment, relationship therapy, family therapy, the treatment of anxiety and depression, stress and trauma related conditions, and the treatment of

children and adolescents (ages 6 and up).

Approach to treatment

Currently, I use a variety of approaches to help clients resolve specific problems and/or develop personal potential. They include among others, Attachment, Psychodynamic, Interpersonal, Cognitive Behavioral, and Mindfulness Techniques. The scope of our work together would include looking at what is happening now, a thorough assessment, and goal setting, as well as making connections between what is happening now and with past experience and relationships. In general, it will be your decision what the focus of each session will be. If you prefer the length of your treatment with me to be limited in time, we will discuss this at the beginning of your treatment. We can discuss the progress of your work at any time, and I will make treatment recommendations accordingly. Please feel free to ask any questions.

Confidentiality

Asha Simpson Psychotherapy, PLLC cannot guarantee confidentiality of information communicated via text, or email.

  1. I have written permission from you to share this information
  2. In the event of a medical emergency, necessary information may given

to emergency personnel or services.

  1. In the event that you threaten to harm yourself or someone else and

that threat is perceived to be serious, the proper individuals will be contacted; this may include the individual against whom you are threatening.

  1. In the event of suspected child or elder abuse, the proper authorities must be contacted. The actions do not have to be witnessed by anyone to warrant reporting.
  2. If ordered by a judge or other judicial officer, information regarding your treatment must be disclosed.
  3. If you bring a complaint against me with the State of Washington, Department of Health, information will be released.
  4. If subpoenaed by an attorney in the State of Washington, records will be released unless you file a protective order within 14 days of the subpoena.
  5. In the event of your death or disability, the information may be released if your personal representative or beneficiary of your insurance policy signs a release authorizing disclosure.
  6. In the event you reveal the contemplation or commission of a crime or harmful act, information may be released to the appropriate authorities.
  7. Information indicating that a minor client was the victim of a crime may be

released to the proper authorities.

I may discuss your case with other therapists in a peer consultation setting or a hired consultant for the purpose of gaining further insight and expertise in meeting your clinical needs. Care will be given to protect you identity. These professionals are also bound to protect your confidentiality.

Fees & Payment

Please understand that payment of your bill is considered a part of your treatment. The following is a statement of my Office and Fee Policy, which I require you to read as indicated, and sign prior to any treatment. My charges are $100 for 50-minute sessions and 150 for initial intake assessments. Full payment is due at the time of service. If I make any phone calls on your behalf I charge each call in 15 minute increments at $25. I accept cash, check, and Visa, MasterCard and American Express. NO Show/ No Call will be charged full session rate payable by client.DSHS and EAP DO NOT pay for sessions you do not attend or cancel in 24 hour time period. Texting to 425‐999-9344 is a convenient way to let me know if an emergency occurs.

Consent for Treatment

I accept, understand and agree to abide by the contents and terms of this agreement and I consent to participate, and/or I have been notified of confidentiality limits and agree to allow information to be exchanged with Insurance Co. I consent to allow my minor children to participate, in the counseling services described above. I consent accept, understand and I understand these are voluntary services and that I may discontinue these services at any time.

Client Signature Date

Client’s Printed NameDate

Client’s Parent or Guardian’s SignatureDate

Client’s Parent or Guardian ‘s Printed NameDate

Asha Simpson, LICSWDate