License Number: 00007297 Olympia, WA 98501

Holly Hodgson, LICSW 924 7th Avenue SE360-742-6071

License Number: 00007297 Olympia, WA 98501

Emergency Services: If you have an emergency, you may call or visit the Providence St. Peter Hospital emergency room at 360-493-7999 or call 911 or contact your PCP office.

Information Disclosure:

You have the right to choose a health care professional who best suits your needs. You have the right to information about their qualifications. Please read through the following disclosure information regarding counseling services. You have the right to refuse services. Stopping therapy early may result in worsening of the initial problems or symptoms that you started treatment for.

Credentials: I am a Licensed Independent Clinical Social Worker (LICSW) licensed with the State of Washington. I earned a Bachelor of Science degree in Psychology from Brigham Young University, Utah in 1997. I also received a Master’s in Social Work degree from Brigham Young University, Utah in 2000. I have been working in mental health treatment since that time until the present.

Approach: My focus in treatment is on an individual client and their goals for treatment. The initial sessions are used for diagnosis and treatment planning. I help patients measure current symptoms, develop specific goals they want to work on in treatment, identify strengths and areas for growth, and share information that will help them to achieve their goals. I use Cognitive Behavioral, Motivational Interviewing, Dialectical Behavioral, and Solution Focused approaches depending on what appears to be most useful for the patient. Homework between sessions is assigned for patients to improve the results of therapy.

Counseling can have risks and benefits: There are options to mental health treatment. As stated above, I use behavioral and cognitive approaches in treatment. Medications can be helpful for some people and this is not a service I provide. You can contact your primary care doctor for questions regarding medication issues. Counseling can bring up issues that are hard to deal with and some people feel worse after participating in treatment. If you are thinking of harming yourself or others, it is important that you inform me. Please talk with me directly if you are dissatisfied with the services I provide. If you decide to discontinue therapy, please discuss it with me first. If you are concerned about my professional conduct you may file a complaint with:

The Department of Health

Health Professions Quality Assurance Division

P.O. box 47869

Olympia, WA 98504-7869

(360)235-4700

Termination options: You have the right to terminate counseling or complete counseling. Additionally, the termination of services can be a mutual decision or, if I determine I am no longer helpful in providing counseling, I can terminate counseling with referrals to other providers.

Confidentiality: I am required by law to report suspected abuse of a child, a developmentally disabled person, or a vulnerable adult that you give me information about. I am required to report how I got the information which means I will disclose some of your private information to assist the investigation of the case(s). I am also required to intervene against suicidal behavior or threatened harm to another, which may include knowledge that a patient is HIV positive but unwilling to inform others which whom he/she is intimately involved. Disclosures may also be made if you sign a written authorization for me to release information about you to another person or agency. If you file a complaint with the Department of Health, the minimum necessary disclosures will be made to present the Department with the full picture. Payment by check allows bank employees to view the names of my patients. Your Health insurance company and/or a third party payer may require that I provide it with information about your diagnosis, treatment plan, and your attendance at therapy sessions. They may require a copy of your entire treatment record. If you are using insurance and/or a third party payer, you acknowledge this and you agree to allow these disclosures.

Fees: My fee for an initial assessment is $140.00; thereafter, it is $100.00 for 45 minute sessions. Payment for therapy and/or copays are expected at the time of each session. If you have health insurance and/or a third party payer, it will usually provide some coverage for mental health treatment. I will fill out forms in helping you receive the benefits you are entitled to. It is important that you discover what mental health services your policy covers. If you have a preferred provider or managed care insurance plan, the fees will be determined by the specific insurance contract. Please check with your insurance company to verify information. I cannot guarantee the accuracy of the information supplied to me. Please be aware that you are responsible for any co-payments or deductibles as determined by your insurance carrier. In insurances where my fees are not determined by contract, you will also be responsible for any fees in excess of that allowed by your insurance company. These fees are to be paid at the time of service.

Your insurance will be billed directly and payment of the insurance portion is generally made directly to me. Please note that I do not routinely bill as fees are expected at the time of service. If you have made arrangements not to pay at the time of service, you will receive a bill. Likewise, if you have an outstanding balance after your insurance has paid their portions of my fee, you will be billed.

I charge $65.00 for cancellations within twenty-four hours and for no-show appointments. Insurances typically do not reimburse for these charges. I do not collect fees in advance of service. You will be charged in quarter-hour increments for telephone calls to me to discuss issues or concerns between sessions prorated based on the session fee of $100.00. The same will apply to telephone interactions I make on your behalf with attorneys, physicians, and others at your request. This fee will also apply to letters and reports you request me to write. You are expected to pay these costs before you pick up the paperwork requested. Insurances will not reimburse for these charges. There is no fee for occasional calls if less than 10 minutes in duration. If you are unable to pay for your part of ongoing services, please let me know and we will discuss options that might include making payments on the bill over an extended amount of time or sliding scales for private paying clients. Co-pays will remain unchanged.

Exceptions to the cancellation and no-show policy: Some insurance plans do not allow providers to bill for cancelled appointments or no-show appointments. Because of this, my policy is to discharge a patient who misses three appointments after late cancellations or no-shows.

Telephone availability: I am available to be contacted by phone 24 hours a day 7 days a week. When I am in sessions, I do not answer the phone. I will look at my messages routinely and return calls in a timely manner. If you are in crisis, I will call you at the first available opportunity to provide you confidentiality. Crisis calls are brief (5-10 minutes) and are for the purpose of giving you some direction for what skills to try. I do not do therapy over the phone.

Vacations: In the event that I am on vacation and an appointment is needed, please schedule an appointment with any of the therapists your insurance carrier recommends. Frequently my colleagues are on the same insurance plans but it is recommended that you check with your insurance and your primary care physician.

Client Records: These are kept for at least eight years of the last counseling date or eight years past the date of the 18th birthday if the client is a minor. Copies of the chart notes are on paper and when time permits, moved to flash drives. These paper and electronic records will be maintained in checking for errors and correcting any errors as well as updating the notes while counseling services are provided, after services are provided, and when transferring data to flash drives. For services in which you were present and if any consent for release of information is required and signed, you may review your hard copy, which may be restricted in limited circumstances. The electronic form of charts are not generally available for review to anyone but this therapist since it contains various client records. Once eight years of the last counseling date for adults or eight years past the date of a minor’s birthday has passed, the records will be reviewed by this therapist and I will decide whether or not todelete the electronic copies. Electronic copies of charts and paper charts will remain in a locked setting.

Acknowledgement of receipt of Disclosure:

Your signature below will acknowledge that:

1. A copy of the information disclosure has been provided to you;
2. You have read and understood the information disclosure as provided to you and had the chance to ask questions.
3. A copy of the Department of Health brochure, published for counseling/hypnotherapy clients and the privacy practices have been provided to you at the same time as this statement.
4. You request and consent to receive counseling from Holly Hodgson, LICSW.
5. You understand that you have the right to refuse services and participate in deciding which services you receive.
6. This subsection does not grant clients new rights and is not intended to supersede State or Federal laws and regulations, or professional standards.
7. You understand that “counselors practicing for a fee must be registered or licensed with the Department of Health for the protection of public and health safety. Registration of an individual with the Department does not include recognition of any practice standard, nor necessarily imply the effectiveness of any treatment”.
8. You agree to allow the disclosure of health information as described above.
9. You agree to be responsible for payment in full of $140.00 for a 45 minute initial session and $100.00 of any 45 minute mental health services thereafter or the fees as determined by the specific insurance contract.
10. You agree to be responsible for payment of last minute cancellations or not showing for your appointment for the fee of $65.00.

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

We collect and create personal information about you and your health. State and Federal law protects your privacy by limiting us in how we may use and disclose such information. Protected Health Information (PHI) is information about you, including demographic information, that may identify you or be used to identify you, and that relates to your past, present, or future mental health or condition, the provision of health care services, or the past, present, or future payment for the provision of health care.

Your rights concerning your PHI.

The following are rights you have regarding PHI that I maintain about you:

• Right of access to inspect and copy. You have the right, which may be restricted only in certain limited circumstances, to inspect and receive a copy of the PHI that I maintain. I may charge a reasonable, cost-based fee for the copying process. You may request a copy of PHI that I maintain in electronic form and format if it is readily producible, but if not, then in any readable form and format as we may agree (eg., PDF). Your copy request my also include transmittal directions to a third party. These requests must be in writing.
• Right to amend. If you feel the PHI I have about you is incorrect or incomplete, you may ask me in writing to amend the information although I am not required to agree to the amendment. You may write a statement of disagreement if your request is denied. The statement will be maintained as part of your PHI and will be included with any disclosure.
• Right to and accounting of disclosures. I am required to maintain an accounting of certain disclosures I have made of your PHI. You have the right to request a copy of such accounting.
• Right to request restrictions. You have a right to request in writing a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. I am generally not required to agree to such a request. If I have been paid in full for all the services covered by such a request, then I will honor a request to restrict disclosure to your insurance.
• Right to confidential communication. You have the right to request that I communicate with you in a certain way or at a certain location. I will accommodate reasonable requests and will not ask why you are making the request.
• Right to a copy of this notice. You have a right to obtain a paper copy of this notice upon request.
• Right of complaint. You have the right to file a complaint in writing with me or the Secretary of Health and Human Services if you believe I have violated your privacy rights. I will not retaliate against you for such a complaint.

My uses and disclosures of PHI for treatment, payment and health care operations

Treatment. I may use your PHI for the purpose of providing you with health care treatment, including management, coordination and continuity of your care with your other current providers.

Payment. I may use your PHI in connection with billing statements I send you. I may use your PHI for the purpose of tracking charges and credits to your account. I may disclose your PHI to third party payers to obtain information about benefit eligibility, coverage, and remaining availability as well as to submit claims for payment.

Health Care Operations.

I may use and disclose our PHI for the health care operations of my professional practice in support of the functions of treatment and payment. Such disclosures would be to business associates for health care education, or to provide planning, quality assurance, peer review, administrative, legal, or financial services to assist me in my delivery of your health care.

Other uses and disclosures that do not require your authorization or opportunity to object.

Required by law. I may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law. Examples are public health records, abuse and neglect reports, law enforcement reports, and reports to coroners and medical examiners in connection with investigation of deaths. I also must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule.

Health Oversight. I may disclose your PHI to health oversight agencies for activities authorized by law such as my professional licensure. Oversight agencies also include government agencies and organizations that audit their provision of financial assistance to me, such as third-party payer.

Threat to health or safety. I may disclose your PHI when necessary to minimize an imminent danger to the health or safety of you or any other individual.

Business associates. I may disclose your PHI to the minimum extent necessary to Business Associates that are contracted by me to perform health care operations or payment activities on my behalf. This may include collection, use, or disclosure of your PHI. To safeguard the privacy of your PHI, such contracts are regulated by the Department of Health and Human Services and must contain provisions designed to limit the use and re-disclosure of your PHI, to require compliance by the Business Associate with your individual rights, to subject the Business Associate to specified security obligations, and to require the Business Associate to require such obligations of a Subcontractor.

Compulsory Process. I will disclose your PHI if a court issues an appropriate order to do so. I will also disclose your PHI if: 1) You and I have been notified in writing at least fourteen days in advance of a subpoena or other legal demand, identifying the PHI sought, and the date by which a protective order must be obtained to avoid my compliance, 2) No qualified judicial or administrative protective order has been obtained, 3) I have received satisfactory assurances that you received notice of your right to seek a protective order, and 4) The time for your doing so has elapsed.

Uses and disclosures requiring your opportunity to agree or object

Prior Providers. I may disclose your PHI to your prior health care providers, unless I have given you the opportunity to agree or object and you have objected in writing.

Close personal relationships. In accordance with good professional practice, I may disclose your PHI to person(s) who are close to you that are involved with your care, unless I have given you the opportunity to agree or object and you have objected. When you are not present or in situations of your incapacity or in an emergency, and where disclosure, in my clinical judgment, would be in your best interests, I will disclose your PHI as minimally necessary.