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Disclosure Statement Form

Disclosure Statement
Laura Fischetti, MA, LMHC
GHC Counseling
206.429.5236
State of Washington Department of Health License #60820585

You have the right to choose a health provider who best suits your needs and purposes. With that in mind, please read carefully the following disclosure information for counseling services. You have the right to refuse services.

Education and Credentials
My highest degree is an MA in Counseling Psychology from City University of Seattle. I also hold a BA in Applied Psychology from City University Seattle. I completed my graduate training at City University Counseling Center. I have been granted the title of Licensed Mental Health Counselor by the Washington State Department of Health. This license is current as of the date of the signing of this document.

Therapeutic Orientation and Approach
I provide therapy from a humanistic point of view with a psychodynamic slant. The goal of the humanistic point of view is to find out how clients perceive themselves here and now, and to help them recognize their own growth, self-direction and responsibility. Therapy from this point of view involves being with you, the client, in the moment, allowing you to talk about feelings, working to understand where you are, and being available to hear what is going on with you. Listening is followed by working together to find the best ways for you to experience growth, healing and change. One of the techniques I frequently use is Cognitive Behavioral Therapy (CBT). After listening to the client and identifying specific patterns of thinking and behavior, and how those thoughts and behaviors impact feelings, I will provide individualized education and homework.

Some examples of homework include breathing or other relaxation techniques when feeling stressed or anxious or journaling in a style that works best for the client; this can include drawing or painting, or other creative methods when appropriate. Any homework is discussed in session, and practiced together, if possible. The psychodynamic slant involves understanding and normalizing challenges in life. Combining these things provides and optimistic method with the goal of helping you, the client, recognize and utilize your strengths in a non-judgmental and understanding setting.

Confidentiality
Your participation in therapy, the content of our sessions, and any other information you provide to me during our sessions is protected by legal confidentiality. Some exceptions to confidentiality are the following situations in which I may choose to, or be required to disclose this information:

• If you give me written consent to have the information released to another party
• In the case of your death or disability I may disclose information to your personal representative
• If you wave confidentiality by bringing legal action against me
• In response to a valid court order or subpoena from the secretary of the Washington State Department of Health for records related to a complaint, report, or investigation
• If I reasonably believe that disclosure of confidential information will avoid or minimize an immediate danger to your health or safety and safety of any other person
• If I have any legal duty, obligation, or right to report

As a mandated reporter, I am required by law to disclose certain confidential information including suspected abuse or neglect of children under RCW 26.44, suspected abuse or neglect of vulnerable adults under RCW 74.34, or as otherwise required in proceedings under RCW 71.05

Appointments and Payments
The fee for a 50 minute session is $120.00. If a client is unable to pay this rate, a sliding fee rate may be applied. No client will be turned away for inability to pay. In order to avoid being charged your session fee for missed appointments, a 24-hour notice of cancellation is required. I am not able to bill 3rd party insurance, but accept cash, check or credit/debit card payments. Payment is due at the end of each session. Teletherapy clients must pay their invoice to avoid missing their next scheduled session.

Telehealth
Not everyone can make it to an office for therapy, and I understand those challenges. This is why I offer teletherapy (also known as telemedicine). The therapy provided via teletherapy is the same that you would receive in the office. The only difference is that you remain in the comfort and familiarity of your residence and meet via video conference. I use doxy.me, a HIPAA compliant video service. Once your session is scheduled, I will provide your link to connect to the platform via a phone or email. You will need a computer with Chrome or Firefox to access doxy.me.

Legal Situations
The services I provide are clinical in nature, not forensic (legal). I do not write letters as it pertains to custody, parenting or service/companion animals because to do so is out of my scope of practice. I do not perform custody evaluation or make recommendations as to court decisions. I do not testify in court as an expert witness, including divorce, child custody, other family law cases, civil, or criminal cases. If however, I am subpoenaed or for any reason required to testify in deposition or in any legal process, your signature below acknowledges that you will pay for all my professional time, even if it is not you who chose to subpoena or request my testimony or participation, and even if my testimony does not serve your interests. I charge $240.00 per hour for my professional time related to any legal involvement. Professional time includes preparation and attendance for legal proceedings, testimony related matters like case research, report writing travel, consultations and phone calls with the attorney, depositions, actual testimony cross examination time, and court room waiting time, even if my services are ultimately not required, such as if a settlement is reached. Signing this disclosure statement gives me permission to release confidential information in courtroom testimony or for any written reports to a Court if legally requested by a court.

Emergencies
If you are experiencing an emergency or crisis, please call 911 or the Crisis Line at (206) 461-3222 or (800)244-5767. In such situations, you may also go to the nearest hospital Emergency Room. WA State Department of Health Contact Information If you would like to file a complaint against myself or any mental health practitioner in the State of Washington, please visit http:www.doh.wa.gov./hsqa/HealthProfComp.htm for more information. You can also mail [email protected] or call (360)236-4700 or send a letter to: HSQA Complaint Intake PO Box 47857 Olympia, WA 98504-7857

By signing this document, you are attesting that you have received, read, fully understand and consent to the disclosures, terms and conditions above, that you have received a copy of your HIPAA and Washington State Notice of Rights and Privacy Practices, have read and fully understand these rights , and have been given opportunity to ask questions.

By signing this document, you are attesting to your consent in counseling services provided by Laura Fischetti MA, LMHC, in-person and/or via telehealth. Once signed, this document will be sent to Laura for her signature and date. A copy will be kept on file.

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May 1, 2024 2:13 pm PDT

Disclosure Statement Form Uploaded by Laura Fischetti - [email protected] IP 205.220.208.250

May 4, 2024 1:19 pm PDT

Document owner [email protected] has handed over this document to [email protected] 2024-05-04 13:19:01 - 205.220.208.250