Professional Disclosure Statement

*Note this document is being revised to reflect my updated LMHC licensure: Retired, Active Status. I am available on a limited basis for consultations. Services are cash/check/CC card pay only at the time of the service. I am no longer on any insurance panels. For clients meeting medical necessity I can provide what is known as a psychiatric super bill, which supports you in working out any reimbursements possible with your insurance carrier. 

Please note below my updated cash pay fee is $200 per hour.

This statement describes the policies of my counseling practice. The information is provided in accordance with standards established by professional counseling and regulatory organizations, including the State of Washington Department of Professional Licensing (RCW 18.19; WAC 246-810), the American Counseling Association (ACA), the National Committee on Quality Assurance (NCQA), and the Health Information Portability and Accountability Act (HIPAA).

Our work begins with a shared understanding of the nature of the counseling process, my approach to services, and your rights and responsibilities as a client. I encourage you to read this document carefully; ask me any questions you have so we can discuss them in order to assure your full understanding of the content. Please acknowledge our attention to this initial orientation by signing at the end of this document.

Therapist Qualifications

Professional Status. I am a Licensed Mental Health Counselor in the State of Washington (#LH00003892). As a condition of licensure and in accordance with professional practice standards, I maintain continuing education requirements in order to provide quality treatment for my clients.

Services. Note this document is being revised to reflect my updated LMHC licensure: Retired, Active Status. I am available on a limited basis for consultations. Services are cash/check/CC card pay only at the time of the service. I am no longer on any insurance panels. For clients meeting medical necessity I can provide what is known as a psychiatric super bill, which supports you in working out any reimbursements possible with your insurance carrier. 

I specialize in general counseling primarily with individual adults. I also utilize a couple modality when partner support is assessed to be helpful to the identified individual patient.  I consult with individuals, couples, and groups on adult development and enrichment issues. I provide mental health consultation to organizations and facilitate groups as interest and schedules allow.

Professional Experiences. I have over 50 years of clinical experience that includes private practice, community mental health, long term care, and acute psychiatric inpatient settings.

Education. University of Oregon, Master of Science in Counseling, 1979. University of Iowa, Bachelor of Science in Psychology, 1972. North Iowa Area Community College, Associate of Art in General Sciences, 1970.

Billing and Fees

Fees.  $200 per consultation hour; workshops and group offerings TBA

I also charge my regular hourly fee for material review, unusual report preparation, copying, lengthy telephone calls, or client approved consultation. I reserve the right to apply a late fee to clinical balances that have been outstanding for more than 30 days.

In order for us to set realistic treatment goals and priorities, it is important to evaluate your resources to pay for your treatment. You will be expected to pay for each session at the time it occurs, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 90 days, and you have not followed through on payment arrangements, I have the option to use legal means to secure the payment and include the legal costs.

Third Party Reimbursement. My fee for third party payers is determined by contract. I will provide whatever assistance I can to support you in receiving the benefits for which you are eligible; however, you (not your managed care/insurance company) are responsible for full payment of my fee. At a minimum, you will be expected to pay at each session whatever portion of the fee is not covered by your managed care or insurance company, unless we agree otherwise or unless your benefit coverage requires another arrangement. If you are interested in continuing your treatment after your benefits end we can discuss how you might arrange that with me as well as any other alternatives that might be appropriate.

Procedure for Raising Fees. If I should determine that my rates need to be raised, I will give you as much advance notice as possible, at a minimum two months. I will discuss the change during our session and post a notice in my office in a visible location.  The new rate will take effect on the date of the notice, unless there we make other arrangements.

Practice Information

Therapeutic Orientation. I use object relations, self psychology, and Jungian principles when working with clients. I believe the therapy process needs to support individuals in exploring problems, finding meaning, and creating choices that are life affirming. I view life as a developmental unfolding. Quite often it is helpful to address the life stage issue reflected in your dilemma.

Counseling Process. Typically 1-3 sessions are needed to develop a shared understanding of the presenting problem and to formulate initial impressions and recommendations.  During that time I develop a diagnosis and screen for indications suggesting the helpfulness of additional psychiatric or psychological assessments. The results of these diagnostic tools are used for developing an appropriate treatment approach for you.

You may elect to begin counseling and continue as long as this serves your needs and inclinations. In the event that I am no longer providing mental health services, I will designate a business associate to meet with you to determine a course of action and referral for services.

Benefits and Risks. There are benefits and risks associated with counseling, and outcomes cannot be guaranteed. It is an individual process. The benefits of counseling include learning more about yourself and your capacity to solve your personal problems. Therapy can be an anchor to help you through difficult life experiences. Risks include the possibility that you will feel worse before feeling better. Another risk is that you may feel stigmatized by the requirement that I provide a diagnosis for you to your insurance company.

You have the responsibility to control your own therapy and to ask questions if you do not clearly understand how we are working together. It is important for you to seek the assistance you need so you can be in control of your therapy and your life.

Making Appointments. You and I will work to schedule appointments at a time that works for both of us. This can be done either over the phone, at the end of a session, or through another mutually arranged alternative. Your appointment time is reserved for you and may be altered up to 24 hours of the scheduled time without penalty.

Cancellation Policy. Your personal work and our scheduled time are important. The full fee will be charged for appointments not cancelled at least 24 hours in advance. Insurance will not cover missed or late cancelled appointments.

Length, Frequency, and Duration of Sessions. Sessions begin at the scheduled time and last for 45-50 minutes. Weekly sessions are typical, but can vary depending upon your circumstances and my availability. The duration of therapy varies with each individual. Some problems may resolve in as few as 1-3 sessions, while other may take 20 sessions, or more. Determining the duration of services will be part of our ongoing dialogue about your needs, progress, and the resources you have available.

Contact Between Sessions. I am usually not immediately available by telephone, but I make every effort to return calls by the next working day.  For purposes of confidentiality, I request that you use my office telephone number, 360- 699-1150, to leave me any messages. In the event that I am unavailable for an extended period of time, I will make arrangements for back-up coverage and inform you of the contact information in that regard.

Termination of Services. You have the right to terminate services at any time. In the event that I should need to terminate services with you unexpectedly, I will make every effort to discuss the situation fully with you and make the appropriate arrangements necessary for your continued treatment.

Psychiatric Emergencies: The metro crisis and emergency services triage line is 360-696-9560. In case of extreme emergency, please go to the nearest emergency room or call 911.

Code Of Ethics. In compliance with requirements of licensure and professional ethics standards, I will not engage in unprofessional conduct, including:

(1) Commission of any act involving moral turpitude, dishonesty, or corruption; (2) misrepresentation or concealment in obtaining a license; (3) false, fraudulent, or misleading advertisement; (4) incompetence, negligence, or malpractice resulting in injury or unreasonable risk; (5) suspension, revocation, or restriction of license; (6) possession, use, prescription for use, or distribution of controlled substances or legend drugs in any illegitimate way; (7) violation of any state or federal statute or administrative rule regulating the counseling profession; (8) failure to cooperate with the disciplining authority by: (a) not furnishing papers or documents; (b) not furnishing in writing a full and complete explanation covering the matter in question, (c) not responding to subpoenas issued by the disciplining board, (9) failure to comply with an order issued by the disciplining authority; (10) aiding or abetting an unlicensed person to practice; (11) violations of rules established by any health agency; (12) practice beyond the scope of practice; (13) misrepresentation or fraud in any aspect of the conduct of the business or profession; (14) failure to adequately supervise auxiliary staff; (15)contact with the public while suffering from a contagious or infectious disease involving serious risk to public health; (16) promotion for personal gain of any unnecessary or inefficacious drug, device, treatment, procedure, or service; (17) conviction of any gross misdemeanor of felony relating to the practice of counseling; (18) procuring, aiding, or abetting a criminal abortion; (19) offering , undertaking, or agreeing to cure or treat disease by a secret method; (20) willful betrayal of a practitioner-patient privilege as recognized by law; (21) violation of chapter 19.68 RCW; (22) interference with any investigation, including pressuring patients; (23) current misuse of alcohol, controlled substances, or legend drugs; (24) abuse of a client or patient or sexual contact with same; (25) acceptance of more than a nominal gratuity from a vendor of health products, suggesting potential conflict of interest. (RCW 18.130.180)

Anyone having questions or wishing to file a complaint about any kind of unprofessional conduct should write to: HSQA Complaint Intake, Post Office Box 47857
Olympia, WA 98504-7857; phone 360-236-4700
Fax: 360-236-2626; email

Confidentiality and Limitations

The law protects the privacy of personal health information and communications between an individual and his/her therapist. In most situations, I can only release information about your treatment to others if you sign a written authorization that meets requirements imposed by state or federal regulations. For any disclosures that require an authorization, I will provide you with an authorization form to complete.

Limitations. There are some limits to confidentiality. These limitations fall into two areas: 1) professional business standards, such as supervision/consultation and billing/administrative functions, and 2) legal obligations/requirements to ensure your health and safety and the safety of others.

I will limit my disclosure to what is necessary and ensure confidentiality by those with whom I conduct my professional business. I will discuss with you any situations where I am legally required to disclose information related to your safety or the safety of another.

My Notice of Privacy Practices for Protected Health Information provides details on authorized, allowable, and required disclosure of personal health information as well as your rights related to your health information. Please review the notice carefully.

Managed Care and Insurance Companies. The counselor-client relationship has long been considered highly confidential and privileged. However, when we work with third party payer support for services, we open this relationship to some level of observation from others.

By signing provider agreements with insurance and managed care companies, I may be required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. It is important for you to know that your mental health diagnosis becomes part of the insurance record unless you request that it not be included (see section on Record Keeping).

Information provided to managed care and insurance companies will become part of the company files that will likely be stored in a computer. Although insurance and managed care companies claim to keep such information confidential, I have no control over your personal health information once it has been sent to them.

Privacy Safeguards. To safeguard your health information, I limit information shared with managed care/insurance companies, billing, and other administrative activities to the minimum necessary. Physical safeguards that I have implemented include filing paper records in a locked cabinet that is not accessible to the public. My computer screen is blocked from view and my computer is turned off when not in use. Electronic records are backed-up and stored in a locked filing cabinet, and my computer is not connected with any other computer systems. In the event I should change computers, I will ensure that all electronic records are removed from my current computer.

Record Keeping. My documentation of services, including documentation for managed care and insurance companies, provides the minimum essential information to justify medical necessity for your treatment. This information includes:

  1. Client name;
  2. The fee arrangement and record of payments;
  3. Dates of service;
  4. Disclosure form signed by counselor and client;
  5. The presenting problem(s), purpose or diagnosis;
  6. Notation and results of formal consultation, including information obtained from other persons or agencies through an authorization for a release of information;
  7. Progress notes sufficient to support responsible clinical practice for the type of theoretical orientation/therapy the counselor uses;
  8. Treatment plan.

Exception: You may request that no treatment records be kept (WAC 246-810-035). If I, as your counselor, agree to the request, and it is permitted by state and/or federal regulations, only the following is required to be documented:

  1. Client name;
  2. The fee arrangement and record of payments;
  3. Dates of service;
  4. Disclosure statement signed by counselor and client;
  5. Written request that no records be kept.

Record Retention. Your records will be kept for a minimum of six years following your last visit, during which time I will maintain them safely, with proper limited access. In the event I am no longer providing mental health services, I will designate a business associate to meet with you to determine a course of action related to ongoing or past services within the six-year period.

Summary of Client Rights

Client Rights. As a client, you have the following rights:

  • To choose a counselor who best suit your needs and purposes;
  • To receive information from your counselor that explains the type of treatment and therapy provided;
  • To expect that the licensed counselor has met the minimal qualifications of training and experience by state law
  • To examine public records which confirm the credentials of the licensed counselor;
  • To report complaints;
  • To be informed of the cost of professional services before receiving the services;
  • To be assured of privacy and confidentiality;
  • To be free from being the subject of discrimination on the basis of race, religions, gender or other unlawful category while receiving services;
  • To receive information about accessing your records;
  • To participate in creating treatment plans;
  • To receive information on alternatives to therapy;
  • To refuse any recommended treatment services or changes;
  • To be informed of potential consequences of refusing services or changes in services.

Disclaimer. Licensing of a counselor by the State of Washington Department of Health recognizes that the counselor has met professional standards of education, training and supervised experience established by the Department.  However, the State of Washington does not recognize any practice standards or imply the effectiveness of any treatment. No specific promises or guarantees can been made about the results of treatment, the effectiveness of any procedures, or the number of sessions necessary for therapy to be effective.


Record Keeping Agreement Informed Consent. Having discussed with Chuck Bender, MS, LMHC the confidential and privileged nature of the client-therapist relationship with regards to the written records, I choose the following record keeping practice:

[  ] Request That No Records Be Kept. I request no treatment records be kept as allowed in Washington Administrative Code (WAC 246-810-035).


Client Signature                                                                                                 Date


Counselor Signature                                                                                           Date

[  ] Request for Minimum Standard Record Keeping. I request limited essential documentation including justification for medically necessary treatment.


Client Signature                                                                                                             Date


Counselor Signature                                                                                           Date

Professional Disclosure Acknowledgment and Agreement.  I understand that I can ask Chuck Bender, MS, LMHC any questions about the terms of this disclosure statement. He has encouraged me to discuss with him my treatment needs and counseling experience.  My signature below indicates that I have read and understand the policies of this disclosure statement and agree to the terms.


Client Signature                                                                                                 Date


Counselor Signature                                                                                           Date

I am the parent/legal guardian/personal representative of _________________________________________.

I have read and understand this disclosure statement, agree to its terms, consent to the client’s treatment, and assume financial responsibility for that treatment

One Comment on “Professional Disclosure Statement”

  1. […] to schedule in person or remote individual, couple, family, and case consultations. Please see my Professional Disclosure page for details on fees and […]

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