It is your right as a client to select the mental health professional who best suits your needs. Before you sign this statement, your consent to treatment requires that you know about my services, and the terms under which I provide them.
I practice according to the Code of Ethics of the Clinical Social Work Association. A copy of this Code is available on request. Please refer to the attached summary of the ethical practices I observe.
I. DISCLOSURE TO CLIENT
A. Credentials
I am a Licensed Independent Clinical Social Worker, and not affiliated with any other practitioner(s). At your request, I can describe the requirements for State of Washington licensure for Clinical Social Work.
B. Confidentiality
The confidentiality of our work is of utmost importance. State of Washington law holds that our communication is privileged information, identical to that between doctors and patients, or lawyers and clients. See Section II. A(b) below.
If your mental health insurance benefit requires a review of treatment to authorize additional sessions, then certain information about you may have to be shared with an insurance or managed care company. I will always review these disclosures with you in advance. Please review the information about my patient Privacy Practices mandated by the 1996 Federal law known as Health Insurance Portability and Accountability Act (HIPAA).
C. Education, training & experience
I received my Masters degree from the University of Southern California School of Social Work. In this program, I completed two one-year clinical internships: a Los Angeles County community mental health clinic serving indigent, severely/persistently mentally ill and homeless populations; and, a corporate employee assistance program (EAP), providing assessment, counseling and referral for personal, work-related and chemical dependency problems.
My post-graduate clinical experience includes individual & family therapy in a South Central Los Angeles psychiatric hospital. I then practiced in a Los Angeles court mandated residential treatment center for adolescent boys, including sex offenders, providing individual, group and family treatment.
I have provided individual and family therapy, case management and emergency room psychiatric assessments throughout Seattle, for Fairfax Hospital. In 1998, I began an office practice in an adjacent clinic, working with psychiatrists, psychologists, nurses, clinical social workers, marriage & family therapists and mental health counselors. I have practiced independently and privately since 1999.
My continuing education has included training in marital therapy, human sexuality, ethics, clinical supervision, workplace trauma debriefing, therapy for children and adolescents, EMDR, conflict resolution, child abuse prevention and reporting, and non-violent crisis intervention. I
have always exceeded State of Washington Department of Health requirements for continuing education hours.
D. Types of psychotherapeutic counseling provided
Couples & relationships, marital and partnership, with an approach that integrates sexuality as
a primary expression of each partner’s sense of self; Adults, specializing in the treatment of depression, anxiety disorders (Panic, PTSD),
grieving, problems related to work and career, and relationships;
E. Counseling methods
No treatment method is more important to me than your belief that we are collaborating in
finding new possibilities for your health and well-being. My methods are guided by understandings of how people develop over time. I am interested in individual growth, and how it is effected by important relationships. I try to get as close as I can to the meanings that you find within these relationships, in your personal and family histories, life events, and the successes and problems of living.
F. Course of Therapy
If you wish, we can agree in advance to the number of sessions in your treatment plan. You have the right to cancel treatment at any time, subject to the 48 hour notice requirement described below in the Statement of Office Policies, Section B. below.
G. Professional associations
I served a two year term as President of the Board of Directors of the Washington State Society for Clinical Social Work from 2008-2010. I maintain membership in the International Critical Incident Stress Foundation.
H. Complaints
If you have a complaint or inquiry about my professional services, you may contact the State of Washington Department of Health. I maintain forms and instructions for such complaint or inquiry.
II. STATEMENT OF OFFICE POLICIES
A. Fees & Payment Policies
Please refer to your signed copy of my Financial Policies statement. Here is a schedule of my fees, as submitted for private payment or for insurance reimbursement:
CPT Code |
Session Type/Duration |
Fee |
90832 |
Individual Psychotherapy 30 mins |
$80 |
90834 |
Individual Psychotherapy |
$150 |
90837 |
Individual/Family Psychotherapy |
$220 |
90839 |
Individual Psychotherapy-Crisis 60 mins |
$180 |
90840 |
Individual Psychotherapy-Crisis, additional 30 mins |
$100 |
90791 |
Initial Appt: Relationship; Individual Diagnostic |
$220 |
Couples Therapy |
Fee |
80 mins {preferred min. appt. length} |
$220 |
110 mins |
$280 |
170 mins |
$400 |
(b) Reports: Authorized releases of treatment information to third parties is accomplished by a report separately written by me (Psychotherapy Notes are separately stored from the Medical Record, as defined by Federal law, and as such the Notes are not typically discoverable.) My charge for writing these reports is $100/hr. The number of hours will be agreed to in advance. Insurance does not reimburse this service.
My fee for phone based professional consultation with other mental health or medical professionals is $100/hr
(c) Appointment policy: In couples therapy, the couple is the client. It presumes the participation of both partners in any appointment. If only one partner appears (for at least 30 minutes) without adequate notice for an appointment, the appointment is recorded as a late cancellation (see II B. below for fee policies.)
(d) Couples records: Records consist of the Medical Record, which contains basic/generic
information about any appointment. Couples jointly hold rights to the Medical Record, so waivers must be signed by both parties in order to release it. More specific and particular content of therapy is recorded in the Psychotherapy Notes, which I maintain separately from the Medical Record. Under the law (HIPAA), Psychotherapy Notes are my property, and are broadly protected, including in legal proceedings like divorce actions, or medical disability applications.
B. Appointment cancellation, rescheduling and changes
Your appointment is an agreement to meet on that date and time. If you do not appear, your credit or debit account will be charged via the pre-authorization in the Personal Responsibility for Payment form.
I accept voice mail and e-mail, for changing or canceling appointments. For Monday appointments, notify me no later than Thursday 12P; for Tuesday, no later than Friday 12P.] If you are late, and do not notify me by phone, I will remain in the office for a maximum of 30 minutes
past the appointment time.
For a late cancellation (less than 48 hours notice): If you reschedule within 4 business days, I charge a fee equal to 75% of what I normally receive from you and/or your insurance carrier. After four business days, the full cancellation fee will be charged. If I fail to appear, without notice, for your appointment, either your insurance co-payment, or your private fee for the next appointment will be waived. (See below,¶2 of Special Office Policies, for Emergency Service notice)
C. Insurance coverage
Most insurance policies cover treatment by Licensed Independent Clinical Social Workers. I bill your insurance company, and they will issue statements to my office and to you of benefits paid or denied. Health insurance carriers need a diagnosis for which they consider psychotherapy treatment to be "medically necessary." I must evaluate on an ongoing basis whether your symptoms meet these 'medical' criteria. If they do not, I cannot submit claims. I can help you evaluate whether this requirement fits with your therapeutic goals.
D. Urgent or emergency contact
I make reasonable efforts to be reachable by phone, text or e-mail if you urgently need to speak to me. I cannot return your call while in session with another client. I will return your call at your request. If your situation is life-threatening or psychiatrically disabling, please dial 911. If you are in a crisis before we are able to speak, call the King County United Way Crisis Line at (206) 461-3222. They can refer you to a community resource, including emergency assistance.
AGREEMENT
Prior to signing below you have the opportunity to ask Robert Odell for further explanation, or have received same, for any of above disclosure information and office policies.
PLEASE NOTE APPOINTMENT CANCELLATION POLICY - 48 BUSINESS HOUR REQUIRED NOTICE