Issues discussed in the course of therapy are strictly confidential. In most cases, information concerning treatments or evaluations may be released only with your written permission. Please read the accompanying Washington Notice Form for more information regarding the privacy of your health information. What follows is a summary of circumstances in which confidentiality may be waived:

Legal Exceptions to Confidentiality: The law requires an exception to the standard of confidentiality under the following conditions: 1) If the treating psychologist has reason to suspect that a child, a developmentally disabled adult, or an elderly person is being abused or neglected, this must be reported to appropriate authorities; 2) If the treating psychologist assesses a client to be potentially suicidal or to intend physical harm to another, steps must be taken to protect you and/or the other person; 3) If the treating psychologist feels a client is unable to take care of basic needs, the psychologist must take steps to assure that these needs are met; 4) If a client should become aware that he or she has AIDS or has become HIV-positive and he or she refuses to be under medical care, the psychologist is required to report this to local health-care authorities; 5) If the treating psychologist becomes privy to actual knowledge of unprofessional conduct by a health professional that places others' mental or physical condition at risk, the psychologist is required to report this to the Department of Health; and, 6) In select legal circumstances, a court of law may have access to treatment records. In the above circumstance in which a release of confidentiality is necessitated, an attempt will first be made to discuss the situation with you.

Other Confidentiality Exceptions: 1) You should be aware that contracts with health insurance companies require that I provide them with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your Clinical Record (i.e. all treatment information in your file with the exception of the psychotherapy session notes). In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. Records which are kept as part of a worker's compensation claim typically have no confidentiality from the Department of Labor and Industries or your employer(this includes your psychotherapy notes). Information sent to an insurance company will become part of their files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. It is important to remember that you always have the right to pay for my services yourself to avoid such potential privacy issues. By signing this agreement, you agree that I can provide requested information to your carrier. You may revoke this agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or, if you have not satisfied financial obligations you have incurred.; 2) Should it be necessary to refer an unpaid bill to a collection agency or small claims court, information necessary to secure payment will become known to that agency.; 3) If you were referred to this practice by a medical professional, legal professional, or therapist, a confirmation note that services have been initiated and a final note that treatment has been completed is customarily sent to the referring source unless you specifically request otherwise.; and, 4) Unless you specifically request otherwise, I may occasionally find it helpful to consult other health and mental health professionals about your case. If I consult with a professional who is not involved in your treatment, I make every effort to avoid revealing your identity. These professionals are legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called "PHI" in the accompanying Washington Notice Form).

My signature below indicates that I have read, understand, and agree to the above policies and also serves as an acknowledgment that I have received a copy of the HIPAA document entitled WASHINGTON NOTICE FORM:

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Client Signature   &    Date

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