Kristen A. Knapick, MA, LMHCA
WA state license #MC60178879
200 1st Ave West Suite 400
Seattle, WA 98119
(206) 779-9178
PSYCHOTHERAPY INFORMED CONSENT & DISCLOSURE DOCUMENT
Therapy is a partnership toward a common goal that relies heavily on honesty and trust. This document is designed to establish those qualities by disclosing your rights and responsibilities to the therapeutic relationship, and by informing you as to what you can expect from me, as well.
My Responsibilities to You as Your Therapist
I. Confidentiality
With the exception of certain specific exceptions described below, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me, without your prior written permission. I will always act so as to protect your privacy even if you do release me in writing to share information about you. You may direct me to share information with whomever you chose, and you can change your mind and revoke that permission at any time.
If you elect to communicate with me by email at some point in our work together, please be aware that email is not completely confidential. All emails are retained in the logs of your or my Internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. Any email I receive from you, and any responses that I send to you, will be printed out and kept in your treatment record.
The following are legal exceptions to your right to confidentiality. I would inform you of any time when I think I will have to put these into effect.
1. If, in my professional opinion, I believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.
2. If, in my professional opinion, I believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform Child Protective Services within 48 hours and Adult Protective Services immediately.
3. If, in my professional opinion, I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police or the county crisis team. I am not obligated to do this, and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call the crisis team.
I have a supervisory relationship with Angie Canelli, LMHC, as I am still in my early years as a professional counselor. As a result, it is common practice for me to consult with him on my caseload. Similarly, in keeping with generally accepted standards of practice, I frequently consult with other mental health professionals in the management of cases. The only purpose of consultation with either my supervisor or other professionals is to ensure quality of care. Every effort is made to protect your identity at all times in these settings.
II. Record keeping
I prefer to take some notes during and after our sessions, and retain them in your records, for both your protection and mine. In the state of Washington, you have the right to request that I not keep any detailed records. If you would like to exercise this option, please let me know, and I will present you with a written request to sign. You have the right to see your records, but because they may not be stored on the premises, you will need to give me 24-hour advance notice to supply them. Your records will be kept for 5-years after your last visit, at which point they will be shredded. All reasonable precautions are taken to secure your records, and they are strictly confidential, with the following exceptions:
1. Records are released with your written authorization, or that of your personal representative, should you become disabled or die.
2. Records are released if you waive privilege by bringing charges against me.
3. Records are released in response to a subpoena from the state secretary, in response to a regulatory investigation, and as required in cases of abuse, neglect, or harm to self or others.
III. Other Rights
You have the right to ask questions about anything that happens in therapy. I’m always willing to discuss how and why I’ve decided to do what I’m doing, and to look at alternatives that might work better. You can feel free to ask me to try something that you think will be helpful, so we might discuss my level of experience with the technique you have in mind. You can ask me about my training for working with your concerns, and can request that I refer you to someone else if you decide I’m not the right therapist for you. Limits of my practice include I cannot diagnose organic or medical conditions of any nature, or prescribe medications for same.
You are free to leave therapy at any time, for any reason. Usually, it will be up to you to decide when to discontinue therapy. If, in my professional opinion, I am no longer serving your best interests, for any reason including an exceeding of my competence, I will refer you to another qualified professional. If you do violence to, verbally or physically threaten, or harass my family, or me I reserve the right to terminate you unilaterally and immediately from treatment. If I terminate you from therapy, I will offer you referrals to other sources of care, but cannot guarantee that they will accept you for therapy.
You have the right to refuse treatment, and the right to choose a practitioner and treatment modality that best suits your needs. The following section is designed to give you a better understanding of what you can expect from my approach.
My Training and Approach to Therapy
I have an MA in Psychology, earned in 2010 at Antioch University Seattle. I am a licensed mental health counselor associate (#MC60178879) in Washington State. My areas of special training and expertise include women’s, gender, and sexual identity issues in general; people in recovery from alcohol and drugs; and people living any number of “alternative” or “fringe” styles of life, including those who work in the sex industry.
My approach to therapy incorporates elements of object relations theory and cognitive behavioral therapy. That is to say that I conceptualize your problems systemically, relationally, and practically. I am interested in how your issues are affecting and affected by all aspects of your life, particularly as they relate to your early childhood relationships. Therapy with me usually begins by collecting information on your view of the issues that brought you to therapy, then moves into a look at your childhood relationships. Together, we will make connections between the two, and use here-and-now techniques that enable you to rewrite your current thinking patterns and subsequent choices, such as cognitive reframing, awareness exercises, self-monitoring experiments, visualization, journal-keeping, and reading books. I am also open to the possibility that biological factors may play a role in your symptoms. If this seems likely to me, I will offer you a referral to a provider qualified to discuss medication options with you.
Therapy has potential emotional risks. Approaching feelings or thoughts that you have tried not to think about for a long time may be painful. Making changes in your beliefs or behaviors can be scary, and sometimes disruptive to the relationships you already have. You may find your relationship with me to be a source of strong feelings. It is important that you consider carefully whether these risks are worth the benefits to you of changing. Most people who take these risks find that therapy is helpful.
In the event that I will be away from the office for an extended period of time, I will tell you well in advance, and give you the name and phone number of the therapist who will be covering my practice during my absence. I am available for brief between-session phone calls during normal business hours. If you are experiencing an emergency when I am out of town, or outside of my regular office hours, please call the Crisis Clinic at 206-461-3222. If you believe that you cannot keep yourself safe, please call 911, or go to the nearest hospital emergency room for assistance.
Your Responsibilities as a Therapy Client
I. You are responsible for coming to your session on time and at the time we have scheduled. Sessions last for 50 minutes. If you are late, we will end on time and not run over into the next person’s session. If you miss a session without canceling, or cancel with less than twenty-four hours notice (weekends not included), you must pay for that session at our next regularly scheduled meeting. The answering machine has a time and date stamp, which will keep track of time of cancellation. The only exception to this rule is if you would endanger yourself by attempting to come (for instance, driving on icy roads without proper tires). A NOTE TO COUPLES/GROUPS: As a therapist for the relationship, it is inappropriate for me to meet with any less than the whole relationship, unless arrangements have been made to do so in advance and with the full consent of all parties. This means that if one of you cannot keep our appointment as planned, I will not meet with the remaining party(ies). Sessions cancelled with less than 24 hours notice will be required to pay for the missed session.
II. You are responsible for paying for your session weekly unless we have made other firm arrangements in advance. My fee for a session is $90.00 for individuals, $100 for couples, and $120 for multi-partner groups/families. If we decide to meet for a longer session, I will bill you prorated on the hourly fee. Emergency phone calls of less than ten minutes are normally free. However, if we spend more than 10 minutes in a week on the phone, if you leave more than ten minutes worth of phone messages in a week, or if I spend more than 10 minutes reading and responding to emails from you during a given week I will bill you on a prorated basis for that time. My fees go up $10.00 every two years, on the even year. If a fee raise is approaching I will remind you of this well in advance.
III. I do not accept insurance, but will accept cash or personal checks. You will be surcharged $25.00 each for the first two checks returned for insufficient funds; thereafter, I will not accept your check. I am not willing to have clients run a bill with me. I cannot accept barter for therapy, nor can I take DSHS medical coupons. Any overdue bills will be charged 1.5% per month interest. If you eventually refuse to pay your debt, I reserve the right to give your name and the amount due to a collection agency.
IV. There are no guaranteed results in therapy. If you’re unhappy with what’s happening in therapy, I hope you’ll talk about it with me so that I can respond to your concerns. I will take such criticism seriously, and with care and respect. If you believe that I’ve been unwilling to listen and respond, or that I have behaved unethically, you can complain about my behavior to:
Health Professions Quality Assurance
Customer Service Center
PO Box 47865
Olympia WA 98504
Email: hpqa.csc@doh.wa.gov
Phone: (360) 236-4700
I am a member of the American Counseling Association, and as such, have agreed to abide by a set of ethical guidelines. If you would like to see a copy of those guidelines, you can request a copy from me, or view one online at http://www.counseling.org/Resources/CodeOfEthics/TP/Home/CT2.aspx
You are also free to discuss your complaints about me with anyone you wish, and do not have any responsibility to maintain confidentiality about what I do that you don’t like, as you are the person who has the right to decide what you want kept confidential.
Client Consent to Psychotherapy
I have read this statement, considered it carefully, asked any questions that I needed to, and understand it. I agree to pay the fee of $______ per session. I understand my rights and responsibilities as a client, and my therapist’s responsibilities to me. I agree to undertake therapy with Kristen Knapick, MA, LMHCA. I know I can end therapy at any time I wish and that I can refuse any requests or suggestions made. I am over the age of eighteen.
[I will ask you to sign an extended version of this document in our first session.]
