Richard C. Walters, M.A., L.M.F.T.	                     2105 112th Ave. NE, Suite 200
State of Washington Licensed Marriage and Family Therapist, number LF00001501		 Bellevue, WA  98004                   
		                     (425) 453-1400

OFFICE POLICIES

Washington State Department of Health requires that all therapists provide clients with the following information.  The requirement is intended to briefly explain the laws that govern therapists and to help you understand your rights and responsibilities as you inquire about therapy.  Please ask if you have questions about the information that follows.

APPOINTMENTS:  Appointments, or sessions, are for 55 minutes.  Once we have established your appointment time, or times, each week, those times are yours and you are financially responsible for the fee even if you cannot make the appointment.  Occasionally it may be possible to change the time for an appointment, so please ask. 

FEES and PAYMENT:  My fee is $155 per appointment.  Payment is due at the time of the appointment, unless other arrangements are made.  For all child custody legal casework, my fee is $465 per hour.

CONFIDENTIALITY:  Everything discussed in therapy is confidential, with the following legally mandated exceptions: you sign a written release and request that specific information be released; if there is imminent threat of harm to you or to another person; if abuse of a child, elderly, or disabled person is suspected; as required for insurance reimbursement; in some instances, under court order.  Please bring up any questions you have regarding the confidentiality of our work together.  I have one other exception for your consideration:  May I thank the person who referred you to me?  Please feel free to circle no if you prefer that option.   No     Yes

QUALIFICATIONS:  I have a master of arts degree in Counseling Psychology from Pacifica Graduate Institute in Carpinteria, California.  I am a Licensed Marriage and Family Therapist, State of Washington number LF00001501.  I have a bachelor of arts degree from the University of Washington.  I have maintained a private practice since 1994.  I am in my fifth year of post-graduate training in psychoanalysis and I use that approach primarily.

COURSE OF THERAPY:  Therapy is a mutual effort and understanding between client and therapist.  As such it is tailored to meet your individual needs.  In general, you can expect that we will discuss your concerns and set goals that we will work toward together.  I will offer appropriate referrals if I become aware of a problem that is outside my area of expertise.  It is important to keep in mind that the process of psychotherapy can be uncomfortable at times. The work of psychotherapy can also be rewarding.

RIGHTS and RESPONSIBILITIES:  You have the responsibility to choose a therapist and type of treatment that best suits you.  You have the right to request a change or to refuse treatment at any time.  Please bring up questions you have regarding therapy in general, or your specific treatment, goals and progress, or my qualifications, at any time.

Washington State Department of Health provides the following information for individuals pursuing therapy: “Counselors practicing counseling for a fee must be registered or licensed with the department of health for the protection of the public health and safety.  Registration of an individual with the department does not include a recognition of any practice standards, nor necessarily implies the effectiveness of any treatment.  The purpose of the Counselor Credentialing Act is to provide protection for public health and safety and to empower the citizens of the State of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct.”  I have included a revised copy of the Washington DOH Pub. 670-001.

I have read and understand the above information about the laws regulating counselors and therapists and give my consent for services:

____________________________    _________________________ _____     ______________________________
Client Signature (s)                                                                                 Date       Richard C. Walters, M. A.			                                                 Revised Sept. 17, 2016