Alison A. Davis, MA, LMHC
Meridian Counseling Services
Alison Davis, MA, LMHC
24604 104th Ave. SE, Ste. 204B
Kent, WA 98030
(206) 291-8466
OFFICE POLICIES AND DISCLOSURE STATEMENT
Welcome. This information has been prepared to acquaint you with my office policies and procedures. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices for use and disclosure of your information for treatment, payment and health care operations.
THERAPIST INFORMATION:
I am a Licensed Mental Health Counselor Associate in the state of Washington. I treat individuals, couples, and families, and I provide group therapy. I received my Master’s degree in Counseling Psychology from The Seattle School of Theology and Psychology. I am also a trained practitioner in the Lifespan Integration method of counseling.
APPROACH TO TREATMENT
My theoretical orientation is based on a belief that effective treatment involves understanding one’s thoughts, feelings, and behaviors, which enables the challenging of old negative voices and patterns of relating that are problematic. I believe this is accomplished by developing a strong therapeutic relationship where both the client and therapist are involved in the exploration of past and present relationships to gain a better understanding of the client’s current relationship patterns. There are many approaches to psychotherapy, but research consistently shows that the most important predictor of success is the relationship between the therapist and client. I believe that treating all of my clients with the utmost dignity, care, and honesty, lays the foundation for growth and change.In my work with clients, I use a variety of counseling methods and techniques, and I am a trained practitioner of the Lifespan Integration method of counseling ( Integration identifies current stressors and traces them back to earlier times when these same feelings were experienced. By showing the “earlier self” that the experience is over, present stressors are resolved and mental and emotional integration occurs.
FEE INFORMATIONAND PAYMENT POLICY:
My fee is currently$120for a 50 minute therapy session. Payment in the form of check or cash is expected at the time of service. I am not set up to take credit cards. Also, it is helpful if you can have your check made out prior to the session so we don’t have to use valuable session time.
APPOINTMENTS ANDCANCELLATIONS
Each session is 50 minutes. When you make an appointment with me, that time is exclusively yours. If you need to cancel an appointment, please do so at least 48 hours in advance. Cancellations made less than 24 hours in advance will be charged full fee.
INSURANCE REIMBURSEMENT
I will provide you with a receipt of our session that includes a diagnostic code. You may submit this to your insurance company for reimbursement. I would be considered an ‘out of network’ provider.
CONFIDENTIALITY
Your therapy is confidential. The law protects the privacy of all communications between a patient and a therapist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by state law and/or HIPAA.
With your signature on a proper authorization form, I may disclose information in the
following situations:
1.I sometimes consult with a supervisor or other mental health professionals to insure the best possible treatment for you. When I do, I make every effort to avoid revealing your identity. These professionals are legally bound to keep the information confidential. If you do not want me to consult about your case, please let me know.
2.If you are involved in a court proceeding and a request is made for information concerning the professional services I provided you, although the law does not protect such information by therapist - patient privilege, I cannot provide any information unless 1) you give me written authorization; or 2) a court order requires the disclosure. You may seek a protective order against my compliance with a subpoena that has been properly served on me and of which you have been notified in a timely manner,
3.If you are involved in or contemplating litigation, you should consult with your attorney about likely required court disclosures.
There are some situations where I am permitted to disclose information without either your consent or authorization: If a patient files a complaint or a lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself
There are some situations in which I am legally obligated to take action in an attempt to protect you or others from harm. These situations are unusual in my practice.
1.If I have reasonable cause to believe that a child has suffered abuse or neglect.
2.If I have reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred.
3.If I reasonably believe that there is an imminent danger to the health or safety of the patient or any other individual, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, seeking hospitalization for the patient, or contacting family members or others who can help provide protection.
* If such a situation arises, I will make every effort to discuss it with you before taking
action, and I will limit my disclosure to what is necessary
USE OF TECHNOLOGY
If you choose to use technology (primarily email) to correspond with me, it is important to understand that your information may not be secure in cyber space as I do not have an encrypted website. I do have a password protected email account and I use password protected access for logging onto my computer.
TRANSFER PLAN
In the unlikely event that I am no longer able to provide services, your file will be turned over to Jeff Davis who will contact you to provide a referral for another therapist. He will keep your records for 5 years. His number is: 206-291-8456.
NOTICE OF PRIVACY PRACTICE
You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in a professional record. It includes information about your name, dates of service, fees, a description of the services provided, your diagnosis, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. You may examine and/or receive a copy of your Clinical Record, if you request it in writing, except in the unusual circumstances that I conclude disclosure could cause danger to the life or safety of the patient or any other individual. A copy fee may apply.
You have the right to:
*Request restrictions on how I use and share your healthy information. I will consider all requests for restrictions carefully, however, I am not required to agree with all of the restrictions.
*Request that I use a specific telephone number and address to communicate with you.
*Request amendments or additions to your health record.
*Request an accounting of certain disclosures of your health information made by me.
*All of these requests must be made in writing.
You may also file a written complaint with the Office of Civil Rights of the U.S. Department of Health and Human Services in Olympia, Washington.
ACKNOWLEGMENT AND AGREEMENT FROM CLIENTS
Your signature below indicates that you have read this agreement and agree to its terms. It also serves as an acknowledgement that you have received the HIPAA brochure, my disclosure statement, a statement of confidentiality, and the notice of privacy practice.
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Client Date
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Client Date
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Client (If minor) DateParent/Guardian Date
CONSULTATION RELEASE
Your signature below indicates your consent for Alison A. Davis to consult with other clinicians as needed to ensure the highest quality of care.
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Client Date
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Client Date