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OFFICE POLICY/SERVICE CONTRACT

Revised March 3, 2016

Welcome to Arlington Psychological Services!

For many people, consulting a psychologist can be a new, possibly anxiety-provoking, experience, and this document can make it worse! Please be aware that the contents of this agreement, while applicable to all, is LARGELY aimed at the 0.0000001% of clients who are a problem. Please, let it scare them, not you.

This policy statement/service contract can cause anxiety, unintentionally, with its legalistic tone (mostly written to protect ourselves from, again, that 0.000000001% of people who fabricate nonsense complaints for personal benefit), and we apologize for the legalistic nonsense of this document. It is not necessary for 99% of our clients. Still, it is designed to answer your questions, clarify the most common issues that clients bring to us, and protect our office from nonsense complaints. There are rare “legalistic” circumstances that we have to address “right up front” to protect everyone involved. Our goal is to develop a fair and clear understanding between us, Arlington Psychological Service (Paul C. Daley, Ph.D. [also known as Dr. Daley]) and you, our new client. Please feel free to jot down any notes and ask about any of these issues at any time.

1

“What are Dr. Daley’s qualifications?”

Paul C. Daley, Ph.D. (“Dr. Daley”), is a Licensed Psychologist (#913). He received his undergraduate training in Psychology from the University of Washington (Seattle, WA), and received his graduate training in Counseling Psychology from Colorado State University, where his Ph.D. was granted in August of 1981. He interned at the Veterans Administration Medical Center in Woods (Milwaukee), Wisconsin. Before coming to Arlington, he served as the Staff Psychologist and then the Program Director for the county mental health center in John Day, Oregon. He has been trained in diagnosis and assessment, individual therapy, marital therapy, family therapy, group therapy, and conflict mediation, and he has a “side” specialty in equine-facilitated psychotherapy (therapy on horseback).

The licensure process in Washington is designed as a protection for the public. The process screens out people who lack minimal competencies. It is unlawful for anyone to present him/herself as a psychologist, or as someone who provides psychological services, without a license. The Examining Board of Psychology can be reached at:

Department of Health

Examining Board of Psychology

1300 Quince Street SE

P.O. Box 47869

Olympia, WA 98504-7869

“What is your approach to treatment?”

Dr. Daley’s orientation to treatment varies with each client and presenting problem. However, in general, his approach might be described as "pragmatic." That is, the type of approach he uses is “finding what works for you,” but the success of your treatment will depend on your motivation, the complexity and clarity of your problems, your personal and financial resources, and your wishes/preferences. For some types of problems, you will need someone to help you work your way through very painful, complex, and confusing feelings and ideas, and a long-term, insight-oriented therapy would be appropriate. On the other hand, if you have a specific goal you want to accomplish (e.g., getting yourself over an irrational fear), these types of problems can often be treated quite briefly. If you have any questions, feel free to ask anyone associated with this practice.

Our first few sessions will involve an evaluation of your needs. For most clients, the process of “digging in” to therapy happens rather naturally, but, if you want to pause and take a moment to discuss Dr. Daley’s impressions and thoughts about how your treatment will proceed, please just ask.

You, too, will be making an evaluation of Dr. Daley, whether consciously or unconsciously. That is good. Therapists vary by personality and “style,” and you want to make sure you will be comfortable working with Dr. Daley. After all, therapy involves a large commitment of time, money, emotional intimacy, and energy, so you should do all you can to make sure it works for you.

Dr. Daley often works by telling therapeutic “stories,” the idea being “a picture tells 1000 words,” “a story can make clear complex concepts that are hard to put into words.” Some people think the stories are just stories, but they are – almost always – metaphorical, a message, a lesson.

“Is there ‘homework’ connected with therapy?”

Sometimes. Between-session work can speed the process of psychotherapy. However, you are not required to complete homework assignments. You would be wise, however, to be thinking about/working on your issues between sessions. You would, in fact, be wise to create your own homework assignments between sessions/appointments (e.g., to think about an important aspect of your last session).

“What is a client-psychologist relationship like?”

A psychotherapy relationship is different than any other relationship. It is not like going to see your Primary Care Physician. Instead, it requires very active efforts on your part. The relationship must develop into a very safe and trusting one where you can feel free to talk about even the most unacceptable thoughts, feelings, and actions. This is much easier said than done. Learning to develop a level of trust that deep may not occur in brief therapy unless you make a conscious choice to take the risk of trusting your psychologist.

“What is the role of a client in this type of relationship?”

Your role in this process is to be as clear as you can (we know it is not easy sometimes) about the problems you want solved, as open and honest about your private thoughts and feelings as you can be (again, we know this can be difficult), and as active as possible in talking about, thinking about, and acting-differently-about your issues as you can be (again … we know it is not easy). Your role is also to keep your "eye on the ball," so to speak. That is, if therapy is not working for you, tell Dr. Daley so adjustments can be made.

Miscommunication is common in all relationships, and a normal part of a therapy relationship, so tell Dr. Daley if you do not understand what he meant, and actively work for clear communication. It is your responsibility to keep the pressure on yourself and Dr. Daley to make sure your therapy works for you.

Think of Dr. Daley as your employee, one with special expertise, but still working under your authority and direction.

Frequently, people come to a therapist expecting to tell the therapist about themselves, and expecting the therapist to say something profound that makes the problem go away. Unfortunately, this seldom happens. Effective therapy involves hard work on the part of both the client and the therapist.

“Are there risks to undertaking psychotherapy?”

Psychotherapy has both benefits and risks. The risks may include experiencing uncomfortable feelings (such as sadness, guilt, anxiety, anger and frustration, loneliness, helplessness, etc.), becoming aware of undesirable aspects of your character, marriage, family, or life, and/or being faced with very difficult and undesirable conflicts/dilemmas. Rarely – very rarely – psychotherapy clients “break down” and require psychiatric hospitalization. (In 30+ years of practice, this has only happened once, and there were complex circumstance beyond just therapy that contributed to the breakdown; the risk of a “breakdown” is probably more theoretical than real.)

Psychotherapy benefits.

On the other hand, psychotherapy has been shown to have benefits for people, and can often lead to such improvements in your life as better relationships, greater inner peace, improved self-confidence and self-esteem, greater appreciation of others, solutions to problems, a stronger sense of self-direction, deeper intimacy, warmer friendships, deeper love, forgiveness of those who have betrayed you, clearer thinking about choices and options, improved conflict-resolution skills, better communication, and significant reductions in feelings of distress.

However, there are no guarantees of what you will experience in your psychotherapy.

“What is ‘Trauma-focused” psychotherapy’?”

“Trauma-focused” psychotherapy is one of many approaches commonly used to treat Posttraumatic Stress Disorder (or similar conditions). It involves, basically, talking about, remembering, and thinking through traumatic experiences while feeling enough “upset-ness” for the memory to be “engaging”/“real” (the process only works if you become emotionally engaged in it), but not so upset as to become overwhelmed. Your therapist, Dr. Daley, helps you to remember, talk about, re-think, and “work through” traumatic experiences, and helps you find a balance between being disengaged versus overwhelmed, with the goal of reducing the amount of long-term “upset” that you experience when thinking about traumatic events.

“Does trauma-focused psychotherapy hurt?

Yes . . . and no . . . Trauma-focused therapy is a therapy that brings you into direct confrontation with the very memories you might prefer to avoid, and yes, the process can be painful. You may, in fact – at first – “get worse” and experience an increase in flashbacks, intrusive memories, intrusive thoughts, nightmares, interpersonal conflicts, etc.

The positive “risk” is that you can – ideally – become desensitized to the traumatic event so that you become able to think about it with significant emotional separation, as something that is over and done with, as opposed to “re-living” the emotional distress every time you think about it.

“Equine-Facilitated Psychotherapy: What is it? And is it meant for everybody?”

Equine-facilitated psychotherapy is, basically, psychotherapy “facilitated” by – helped by, improved by, enhanced by – the use of horses and “Mother Nature.” There are actually several ways to use horses to facilitate “healing,” but Dr. Daley’s way is simply to conduct psychotherapy while riding horses in the forests/hills/mountains. In actuality, the psychotherapy component of Equine-Facilitated Psychotherapy is not much different from what happens during psychotherapy in the office. Similar topics are discussed, the “doctor-patient relationship” is the same, the goals of therapy are the same, the process is the same (we talk, we explore, we wait, we debate, we cry, we wish, etc.), but we do it on a peaceful ride in the woods astride horses (who might, VERY RARELY, at any moment, erupt in a dramatic explosion of horse-upset-ness), warmed by the sun, entranced by the snow, “hypnotized” by the quiet, soothed by the rain, re-calibrated by the vista, and probably, instructed by the horses and the simplified ways they exist.

If you prefer, we can just walk in the woods and lead the horses.

You should be aware that horseback riding can be both very peaceful and relaxing, AND potentially quite dangerous, and, before you can benefit from equine-facilitated psychotherapy, you have to desire the peace and be willing to risk the danger.

Equine-facilitated psychotherapy is a very minor aspect of this practice. If you are interested, talk it over with Dr. Daley.

“How long does therapy usually take?”

The length of your therapy depends on two major points:

1) the nature of your problems.

If your problems are simple and specific (for example, getting your children to do their chores), the total number of sessions will be smaller (perhaps 1 to 10 sessions). If, on the other hand, you are seeking help in overcoming a depression that has troubled you most of your life, your treatment could take 20 to 200 or more sessions.

2) your effort and hard work. . .

Studies indicate that the more strongly motivated and firmly committed you are to change, the more rapidly therapy can progress. Your motivation for change – not just your desire, but your hard work at it – is more critical to the success of therapy than Dr. Daley’s skills.

Please feel free to discuss the likely length of your treatment with Dr. Daley.

“When are psychological tests administered?”

Occasionally, Dr. Daley may ask you to take one or more psychological tests. Some of these tests are simple forms that you fill out on your own. Others are tests administered by Dr. Daley. Some tests are computer scored. Typically, Dr. Daley will go over the results of the tests with you at your next session. You may also ask to be tested. There are additional fees for most psychological tests (see “What are your fees?” below).

“Do you consult with other mental health professionals about your clients?”

Sometimes, yes. Good therapy practices suggest that it is wise for psychologists to sometimes review their clinical work with a respected and knowledgeable colleague. Dr. Daley sometimes meets with other therapists to discuss cases. In addition, depending on the special needs of each client, he may seek the consultation of physicians, other psychologists, or psychiatrists. All conferences with individuals outside of this office will be made either with your permission, or without disclosing identifying information. You have a right to ask us not to consult with specific other professionals.

“Who decides when to stop therapy?”

First of all, really, you decide when to stop therapy. You are the boss, and Dr. Daley is your educated employee. However, it is better for you if the decision to stop therapy is made mutually, between you and Dr. Daley.

Discussions of the termination of therapy should take a minimum of one full session. “By the way, I'm not coming anymore” or just “disappearing” from therapy robs you of the opportunity to confront and express tender and embarrassing feelings, disappointed or angry feelings, and all of the complex reactions associated with the loss of an important relationship. Clinical lore suggests that the memories of your therapy and therapist may remain with you for 10 or 15 years after therapy ends. Having a discussion of your thoughts and feelings (positive and negative) associated with ending therapy can significantly aid your transition out of a therapy relationship.

Sometimes the stopping of therapy is not smooth. The process of talking over painful subjects can become very uncomfortable, and you may find yourself wanting to suddenly quit therapy. You may disagree with the direction of the therapy or feel impatient for faster or greater change. If these feelings happen to you, please talk with Dr. Daley before making any decisions. Please remember, though, that you have the right to stop treatment any time you want to, and to refuse some or all of the services provided at this office. If you wish to discontinuing your therapy here, you may ask us for a referral to another therapist.

“What are your ethical and professional standards?”

Dr. Daley is bound by the Code of Ethics of the American Psychological Association and by state laws regulating the practice of psychology and psychotherapy. See ( Update/ Psychologist/Laws).

If you have questions about Dr. Daley’s professional behavior, you may want to follow a two- or three-step procedure.

First, you should get a copy of the American Psychological Association's "Ethical Standards" from our office, the Washington State Psychological Association, or the American Psychological Association. After reading through these standards, you should either sit down with Dr. Daley and discuss your concerns, or file a formal complaint with the Department of Licensing, depending on the nature of your complaint. These options may put you on the "horns of a dilemma." You might not want to directly confront Dr. Daley, and you may not be clear on the seriousness of the problem. To help clarify the issues, you might consider consulting an impartial Licensed Psychologist for advice. Most psychologists will provide this service for free.

Does your staff have access to clinical/private/privileged/“secret” information about me?

Yes, support staff DO have access to clinical information about you. When Dr. Daley writes a letter, the support staff usually “process”/type it, and they often edit letters and reports for clarity, spelling, punctuation, etc. Support/clerical staff also have access to your diagnoses and other billing information. If your managed care company requires us to fill out various forms, support staff often have access to the information in those forms because they sometimes have to fill out portions of the forms. The support staff at this office are not only trained in the strictest understanding of the meaning of confidentiality, but, with the new HIPAA regulations, they are now required to sign a confidentiality agreement in order to maintain their employment in offices like this (in which confidentiality is so crucial). You may ask that confidential/clinical/ private/“secret” information NOT be shared with support staff (although we ask that, except under special circumstances, you make this an all-or-nothing request [that is, it would be very difficult for us to keep track of requests to keep only certain bits of information away from the support staff, and much easier for us to keep everything away from support staff; be aware that we cannot agree to keep the information needed to bill for services secret from the support staff who do our billing, unless you wish to pay for your services “out of pocket”]).

“Tell me about the cost/process of the first session .”

The first session is designed to acquaint you with Dr. Daley, answer your questions about how therapy works, and begin identifying problems and treatment goals. The cost for this first session is higher than the cost for ongoing therapy sessions because the work involved in setting up a new “client” is more extensive.

What if all I want is ONE session?

If you desire "single session" treatment, we will want to schedule a two-hour session. Charges will not be prorated if you do not need the entire two hours, but, in all likelihood, we will use all of the time. There are no reduced fees for single session therapies.

“How long is a therapy ‘hour’?”

A regular therapy appointment is 45-50 minutes in length. Please understand that if you arrive late, your appointment hour will not be extended (ususally another client is scheduled after you). However, you will still be charged for the full “hour,” since that is the amount of time reserved for your appointment.

“What if I need to cancel an appointment?”

As long as you provide 24 hours notice, there will be no charge. If you cancel with less than 24 hours notice, you will be charged as described in the following section.

“What if I simply do not show up for my appointment?”

Because your therapy “hour” is "reserved" for you, the first time you do not show up for your appointment, you will not be charged. The next time you “no-show” or cancel with less than 24 hours advanced notice, you will be charged $50, and the charge will go up $50 each time you no-show or cancel with less than 24 hours notice until the charge reaches the full fee, after which you will be charged the full fee for each no-show or cancellation with less than 24 hours advance notice. Remember, your health insurance will not cover missed appointments.

We are not allowed to implement this policy with veterans, so we ask veterans to please respect that no-show or cancellations with short notice deprive us of income and other clients of using that hour.

“What are your fees?”

Initial Consultation $22500 per hour

Individual, Marital, or Family therapy* $17500 per hour

Group therapy $4500 per hour

Divorce Mediation or Parenting Plan Mediation $17500 per hour

Equine Facilitated Psychotherapy $20000 per 2 hours

Court or Attorney referred evaluations $25000 per hour

Courtroom testimony, preparation, depositions, and/or standby $25000 per hour

Psychological Evaluations and Testing $22500 per hour

Report preparation $22500 per hour

Emergency services $22500 per hour

Phone consultations $22500 per hour

Computer scored tests $3000 to $7500 per test

“Who has final responsibility for the bill? Me or the insurance company?”

READ THIS SECTION CAREFULLY:

Remember that you are, ultimately, responsible for your entire fee/bill.

If you have health insurance coverage, we will bill your insurance company for you, as is standard practice in most health care offices, if that is what you want us to do (which most people DO want), but any problem(s) with the insurance coverage become your responsibility to resolve. (We will gladly help you in any way possible, but the ultimate responsibility for the cost of services here is yours.) If you do not pay us, we will send your bill to collections.

AN OPPORTUNITY FOR YOU TO SAVE MONEY (but BE FOREWARNED...):

COLLECTING MONEY FROM HEALTH INSURANCE COMPANIES TAKES, INITIALLY, ENORMOUS EFFORTS/TIME/PERSISTENCE [BUT THEN GETS EASIER … UNTIL THE NEXT CHANGE OF RULEs/LAWS/PROCEdures/regulations]. They – the insurance companies – do NOT simply pay the bill. They demand this and that, and then this and that and then this and that and then this and that and then this and that and then this and that and then this and that and then this and that and then this and that and then this and that and then this and that and then this and that and then this and that and then this and that and then this and that for, sometimes, months on end, months and months and months on end (sometimes YEARS). We will handle that process for you, but you MIGHT want to pay us yourself, “out of pocket,” from your own financial resources, and then bill your own insurances yourself, saving yourself 25% of your fee. If you elect to bill your insurance company yourself, we will ONLY provide you with your diagnosis and dates of service. YOU will have to deal with all of the other nonsense your insurance company demands.

Advantages and disadvantages of our offices billing your insurance...

If we bill your insurance for you the ENORMOUS hassle of it is taken off your shoulders and placed on ours, a normal part of business, a non-event. But we charge for that work. Approximately 25% to 50% of the fee we charge goes towards getting paid for the work we do. You are freed from an ENORMOUSLY difficult process. We take on that ordinary “cost of doing business,” and we do it gladly, happily. You are saved, rescued, from a hassle of, literally, ginormous proportions. For most people, most of the time, it is worth the “cost” of having our offices bill for your services. More than 50% of our clients have no “co-pay,” so having our offices deal with the enormity of the hassle of insurance billing makes complete sense.

However, if you decide to pay out-of-pocket, once all of the “and then this and that and then this and that and then this and that and then this and that and then this and that and then this and that” nonsense is handled, it becomes a VERY EASY task to collect back your money … until the next change in employees/rules/regulations/nonsense, at which time it becomes EXTREMELY difficult to get your money (for between one week and one decade), after which it becomes very easy again … until the next change in laws, employees, rules, regulations. ...

The politically incorrect truth of it:

While the “politically correct” advice would be for you to carefully read the section in your insurance coverage booklet that describes mental health services, as re-written for the 10th time by lawyers who are not on your side, nobody really does that. Call them, your insurance company. Ask about your coverage, and ask them to send you some summary of your mental health benefits. Of course we will also provide you with whatever information we can, based on our experience, and we will be happy to help you in understanding the information you receive from your insurance company. We are also willing to call your insurance company on your behalf, if you like.

“Managed Health Care” often requires “authorization” before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches. It may be necessary to seek bureaucratic approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some clients feel that they need more services after managed care benefits end. Some managed-care plans will not allow you to continue to see the same therapist once your benefits end. If this is the case, we will do our best to help you find another provider who will help you continue your psychotherapy. Because such treatment of client could be considered unethical, we MIGHT be willing to treat you for free, under limited circumstances.

Insurance requirements.

You should be aware that most insurance companies require us/Dr. Daley to provide them with your diagnosis and dates of service. Sometimes they ask for additional clinical information such as treatment plans or summaries (e.g., L&I and the Veterans Administration), or copies of the entire record (in rare cases [e.g., L&I and the Veterans Administration]).` This information will become part of their records and will probably be stored in a computer. Though all “insurance”/“third party payors” claim to keep such information confidential, we have no control over what they do with private information once it is in their hands. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any reports we submit, if you request it.

If you have been referred by a managed care company or an EAP, it is your responsibility to make yourself aware of the rules, limitations, benefits, etc. of that company, and to provide us with clear (preferably written) documentation of your wishes if you do not want us to comply with any of those requirements (typically, you will have signed a document with those companies indicating your agreement to their program specifications, and we have no way of knowing that you do not wish us to comply with some aspect of their plan unless you tell us).

“When is payment for services due?”

Payment of your portion of the fee is due right before or after each session. To help you keep your own records straight, we will mail you a statement each month indicating how many sessions were billed to your account, how much you paid, and how much the insurance company paid. You are responsible for the entire bill/fee (after insurance company “adjustments”). This process is very complicated. Insurance companies take a very long time to pay for services, and then document the process in a very confusing manner.

“What happens when I fall behind on my payments?”

This is a rare event because you will be asked to pay for your portion of your services at the time they are rendered/delivered, on your way in the door. However, should you fall behind on your payments, we will not assess any finance charges as long as some payment is made each month. If a payment is not received for more than one month, a 1.5% per month finance charge (18% per year) will be assessed (computed on the outstanding balance each month).

Delinquent accounts may be turned over to a collection agency, or we may initiate action against you in small claims court if we cannot work out a payment schedule with you. You will also be responsible for the cost of our efforts to collect our fee from you. If we have to pursue payment from you through a collections agency or small claims court, we will release your name, your address, your social security number, your date of birth, your employer, your work phone number, the amount due, the fact that Dr. Daley provided a professional service to you, the dates of service, any other data/information demanded by the processs, and whether or not mail we have sent to you has been returned. We will NOT release any protected or confidential information about you.

“What if there is a disagreement with they monthly statement/bill or a problem with payment?”

If you have any problem with your bill or making your payment, please let us know right away. Most billing errors/“issues” are the result of a simple oversight, and conflicts can usually be settled through discussion and negotiation, easily. Payment problems are almost always easily negotiated.

“How can I reach Dr. Daley after-hours?”

Dr. Daley is USUALLY available by cell phone (3608093765) after hours, but if he does not answer, and you have an emergency, you can call 1-800-584-3578 or a national crisis line at 1-800-273-8255. Dr. Daley DOES NOT PROVIDE EMERGENCY SERVICES. If you have a mental health emergency, call one of the above number, or 911, or go to the emergency room at the local hospital. You can also try the emergency services at the local mental health center.

“Do I have the right to see my records?”

Our offices keeps a record of the health care services Dr. Daley provides to you (for example, summaries of your sessions, test results, and reports). You may ask to see and have a copy of those records, or Dr. Daley can provide you with a written or verbal summary of your records, as you prefer. You will be charged for the retrieval and copying of your records AND for a professional review (by Dr. Daley) to insure that your records do not contain information that could harm you. These charges will be in accordance with the current acceptable fees for such practices. If the record contains references to others (e.g., your spouse), it will require special review and preparation (in order to protect their privacy), at an additional fee.

To see your record, please schedule an appointment with Dr. Daley. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. Dr. Daley will offer to review your record with you so that he can explain any technical language, any of the assessment terminology used, answer any other questions you might have, and so that he might try to sooth any pain that disclosure creates for you. He is also available – through eternity – to clarify the records for other parties/people/entities, at your request. However, you have a right to force him to release your records without such review.

What if there are errors in my records?

You have the right to ask to have your record corrected. It is preferable that you submit the corrections you desire in writing, but, if you cannot or will not do that, we will help you. The goal is to make the records accurate. Dr. Daley and these offices have the right to refuse to make corrections that are deemed inaccurate.

“How confidential are the services I receive from Arlington Psychological Services?”

The confidentiality of psychological information is extremely strict. This office will not tell anyone that you are coming here – let alone what is discussed – except under the following circumstances:

1. You may ask Dr. Daley to disclose confidential information to someone (for example, to your physician or another therapist). If this happens he will SOMETIMES, usually (HIPPA rules do not require disclosure between treating providers, but ALLOW disclosure) ask you to sign a release form that specifically states what information can be released, although you should be aware, again, that the laws of the land allow health care providers to communicate with each other WITHOUT your permission. You must ask us NOT to communicate specific information to specific providers, if that is your preference. We will comply with such requests. Ideally, you should provide us with such request in writing, but if you cannot or will not, we will document the request in writing ourselves.

2. Dr. Daley may ask you for permission to disclose confidential information to another professional (for example, to consult with another therapist, psychologist, medical provider, or psychiatrist). You do not have to agree to this request. If you do agree, we will ask you to sign a release form that specifically states what information can be released. If you do not want information disclosed, except as specified below, we will honor your wishes.

3. In cases of medical emergency, if Dr. Daley knows something that could save your life, he will disclose this information without your permission. Obviously, this rarely occurs.

4. Dr. Daley is also a “mandated reporter.” This means that he is required by law to inform the proper authorities – even if you do not give your permission – if he believes you are:

a) of immediate danger to yourself (e.g., suicidal);

b) of immediate danger to others (e.g., homicidal [Dr. Daley is required to not only inform the police, but to inform potential victims, and, under certain circumstances, he may be required to have you involuntarily hospitalized]);

c) of immediate danger to others’ property;

d) unable to meet your own basic needs (for example, for food and shelter);

e) physically, emotionally, or sexually abusing children or a disabled person(s); or

f) physically, emotionally, or sexually abusing an elderly person,

Please note that some clients may think about suicide – even seriously – and Dr. Daley is NOT under any obligation to report these thoughts to anyone. Dr. Daley is only required to disclose this type of confidential information without your permission if he honestly believes you will kill yourself (or others) in the immediate future.

If you are abusing children, the disabled, or the elderly, Dr. Daley will always encourage you to make the report to the authorities yourself (things tend to go better that way). However, whether or not you make this report yourself, Dr. Daley is required by law to make such a report to authorities himself. Please keep in mind that he is here to help, he is not an officer of the law, and that every effort will be made to handle the report of such issues in a dignified and therapeutic manner.

5. A court of law may subpoena your records.

Generally, the confidentiality of your relationship with your therapist/Dr. Daley is protected by law and you will usually have the right to stop Dr. Daley from providing any information about your treatment (if it is subpoenaed), but Dr. Daley might be required to testify under certain circumstances, examples of which are:

a) if the court rules that other legal issues outweigh your right to the protection of your privacy (e.g., you become a mass murderer);

b) if a case involves custody of your children (because your mental health – and that of the other parent – may become central issues in such cases);

c) if a case involves questions of your emotional conditions (e.g., if you apply for benefits of some sort based on your assertion of having suffered emotional problems);

d) if the court rules that you have already broken confidentiality by discussing your therapy with someone else (e.g., if you talk over your therapy with your boy/girlfriend, the court might rule that you violated your own confidentiality); or

e) if the court sent you to us for psychological evaluation, and you agreed to participate.

6. Under Washington State Law, health care providers (including mental health providers) must or can disclose information about you under certain circumstances. Although Dr. Daley does not anticipate being asked to disclose any information about you under this law, you should know about the law and what it would require or allow us to do:

a) technically, we are allowed to disclose information – without your permission – to your physician or any other health care provider who works with you if we feel this is in your best interest;

b) technically, we are allowed to disclose information – without your permission – to immediate family members or to an individual known to have a close personal relationship with you if this is done according to the rules of good professional practice, and justified by the need to provide you with appropriate health care;

c) we are allowed to disclose some information – without your permission – if we are involved in a research project that has been approved by a human subjects review panel;

d) we are allowed to disclose certain information – without your permission – if we are subject to a financial audit;

e) we are allowed to disclose information about you – without your permission – to an official of a penal institution if you are imprisoned;

f) we are allowed to disclose information – without your permission – to federal, state, or local law enforcement authorities to the extent which the health care law requires it; and,

g) we can disclose certain portions of your records to appropriate authorities engaged in collecting data for legal, administrative, financial, billing, or actuarial services provided to this office.

Normally, even when the law says we do not need your permission, we will ask you for it anyway.

2

“What if I am not yet 18 years old?”

In the treatment of teenagers, there is a delicate “confidentiality balance” that cannot be fully resolved. On the one hand, establishing a trusting relationship with a teenager can be a very delicate and difficult task, and if the teen feels that his/her confidences will be betrayed, s/he is unlikely to confide in the first place. On the other hand, teenagers can do a remarkable job of pointing themselves in frightening directions in life, and parents might rightfully feel betrayed to suddenly learn that their teen’s psychotherapist knew of their impending dysfunction, and never said a word.

Teens in therapy and their parents need to decide “which way to go” with this issue. As a parent, do you want to grant confidentiality and risk being shocked at what the teen does, or ask for regularly scheduled feedback and risk that, in the process, the teenager does not reveal relevant or significant information?

If you are under 18 years of age, please be aware that the law may provide you with the right to confidentiality, but it also makes you financially responsible for your treatment. Parents are only responsible for payment for services if they agree to be responsible.

No matter what agreement is reached between a teenager, the parents, and Dr. Daley, if Dr. Daley thinks that the teenager is at immediate risk of suicide or homicide, he/we will notify the parents (and police) of this concern.

“Could there ever be a situation in which I want Dr. Daley to provide information to someone and he might refuse to do so?”

The surprising answer to this question is "Yes.” … and No. That is, sometimes clients want to use therapy records in an inappropriate fashion. Dr. Daley’s code of ethics requires him to do all that he can do to prevent the misuse of psychological information, by you or against you. If you request your records, and Dr. Daley learns of your intention to use the information therein inappropriately, he will make every effort to insure that you fail in the effort. For example, if you only came to therapy to try to prove that your ex-spouse is a poor parent to your children, Dr. Daley will make note of that fact in the information he releases.

If Dr. Daley is compelled to testify in court in my case, are there fees?

If Dr. Daley is compelled by a court of law to testify, you will be required to pay his fee – in advance – for travel to and from, attendance at, and preparation for any legal proceeding even if his testimony harms your case, and even if he is never actually “called” to testify.

Your best “stance” in therapy is to use Dr. Daley as your therapist – and only your therapist (unless you are only here for a psychological evaluation) – and leave everything else out of the process. The process is meant to be private, confidential, softly inviting of insight, not part of some legal action.

“What if all I need is a Psychological Evaluation?”

If you have consulted us in order to obtain a psychological evaluation – or been referred ONLY for a psychological evaluation – and you are not seeking further services, we will continue to make every effort to maintain an open and clearly-communicating relationship with you. However, this process can be complicated by circumstances surrounding your referral. For example, if you have been forced to seek an evaluation by a court of law, or if you are embroiled in some type of legal battle, you may not feel like you want to be completely open with Dr. Daley. You may be angry about having to submit to a psychological evaluation. These issues should be discussed with Dr. Daley.

If someone else is paying for the evaluation, then that other person/entity, that “third party” (third to you and Dr. Daley) becomes the “client” of this office. That is, the person/agency paying for services “owns” the rights to decide what to do with the “product” of the assessment, the written report.

If you have been forced by a court of law to undergo an evaluation, you have the right to question us in detail about the evaluation procedure, as well as the right to refuse to participate in the evaluation. If you choose to participate, though, the confidentiality of the evaluation will extend (within the limits outlined in this document and the law) to everyone except the court or third party that ordered (and paid for) your evaluation. That is, the final report will be released to the person or agency or entity that asked for and paid for the report, regardless of whether or not you want the report released to them.

Three factors often surface when an agency pays your fee. First, many examinees are confused by the referral, and request an evaluation "because they told me I should come here." Please recognize that psychological evaluations can have major impacts on your life and your benefits with these agencies, and you should be fully informed as to the nature of – and reason for – the evaluation. Secondly, when an agency is paying the fee for your evaluation, that agency earns the right to receive the written report of your evaluation, even if you are displeased with some or all of the report. If an agency (e.g., Division of Vocational Rehabilitation, Labor and Industries, Division of Disability Determination Services, Division of Child and Family Services [or other agencies]) is paying for your evaluation, you may refuse to begin the evaluation, but you cannot retrospectively revoke your permission to disclose confidential information to the referring agency unless you pay all of the fees involved. Finally, by your signature below, you are agreeing not to use an evaluation conducted at one agency's request for subsequent legal or court issues, or for use by other agencies asking different evaluative questions.

If you desire feedback about your evaluation, you may schedule an additional session to review the evaluation (the referring agency may or may not pay your fee for this "extra" session, and payment must be arranged in advance). Written reports will not be released until the fee for the evaluation has either been paid or guaranteed. Written reports will not be released to legal representatives or courts until Dr. Daley has gone over the final report with you so that you understand the exact nature of what is being disclosed. Again, if you have any questions, ask.

Agreements

By your signature below, you are:

1) agreeing to pay your fee in full,

2) agreeing that you will not subpoena Dr. Daley or his records for any past, present, or future legal or administrative actions with which you become involved unless your initial referral was for a psychological evaluation, and you disclosed – in advance – that the records would be required for this particular legal action, and

3) agreeing to the terms set forth in this policy.

If you have questions, conflicts, or problems with any aspect of this policy, please negotiate a mutually agreeable resolution with Dr. Daley within 10 working days. Barring any discussion, this policy will take on the full force of a contractual agreement after 10 working days from your signature below.

Summary

There is a fine line between providing people with information versus overwhelming them with information. This policy statement is intended to help you make informed choices about your psychological services. Indeed, it is very rare that serious problems ever arise. Please feel free to ask Dr. Daley any questions, or offer him feedback about any aspect of this practice.

Paul C. Daley, Ph.D.

Arlington Psychological Services

I have received a copy of the Arlington Psychological Services Office Policy/Service Contract number 03031602 and I agree to abide by the conditions therein. By my signature below, I am agreeing to the terms set forth in this policy. If I have questions, conflicts, or problems with any aspect of this policy, I have the option of negotiating a mutually agreeable resolution with Dr. Daley within 10 working days of my signature below. I understand that, barring any discussion, this policy will take on the full force of a contractual agreement after 10 working days from the date of my signature below.

Do you want us to be able to leave messages (e.g., appointment changes) at your home?

|Please initial one: |Yes_____ |No_____ |

Do you want us to acknowledge that you are a client here to people who tell us that are related to you?

|Please initial one: |Yes_____ |No_____ |

__________ ________________________________________________

Date Signature

__________ ________________________________________________

Date Signature

__________ ________________________________________________

Date Signature

SPECIAL ARRANGEMENTS:

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

I have received a copy of the Arlington Psychological Services Office Policy/Service Contract number 03031602 and I agree to abide by the conditions therein. By my signature below, I am agreeing to the terms set forth in this policy. If I have questions, conflicts, or problems with any aspect of this policy, I have the option of negotiating a mutually agreeable resolution with Dr. Daleywithin 10 working days of my signature below. I understand that, barring any discussion, this policy will take on the full force of a contractual agreement after 10 working days from the date of my signature below.

Do you want us to be able to leave messages (e.g., appointment changes) at your home?

|Please initial one: |Yes_____ |No_____ |

Do you want us to acknowledge that you are a client here to people who tell us that are related to you?

|Please initial one: |Yes_____ |No_____ |

__________ ________________________________________________

Date Signature

__________ ________________________________________________

Date Signature

__________ ________________________________________________

Date Signature

SPECIAL ARRANGEMENTS:

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

-----------------------

Employer: ______________________________________

3 Is your condition related to an on-the-job injury?

1 Yes_____ No_____

4 Name:___________________________________

First M.I. Last Maiden

5 Address:_________________________________

__________________________________

City State Zip

1 Today’s Date: _____/_____/_______

2 Referred by:________________________

1 Have you ever been psychiatrically hospitalized?

2 Yes_____ No_____

If so, where? ___________________________________

Name of Hospital/Treatment Facility

____________________________________

Address

____________________________________

City State Zip

Who is your Family Doctor?

_________________________ ( ) ______________

Name Phone

List your medical conditions:_____________________

______________________________________________

List your current prescription medications:

______________________________________________

______________________________________________

6 Home Phone: ( ) _______________________

May we call you at home? Yes_____ No_____

Work Phone: ( )_____________________

May we call you at work? Yes_____ No_____

Cellular Phone: ( ) ___________________

FAX: ( ) _________email:____________

May we contact you by email? Yes_____ No_____

SSN:_____-___-______

DOB: _____/_____/_____ Age: ________

Gender: Male _____ Female _____

Marital Status: ___________________________

Name of Responsible Party:

____________________________________________

7 Responsible Party’s Address:

8 ____________________________________________

____________________________________________

City State Zip

Responsible Party’s Phone: ( ) ________________

Responsible Party’s Work Phone: ( ) ___________

Responsible Party’s email: _____________________

9 Any previous mental health treatment/counseling?

1 Yes_____ No_____

Previous therapist’s name and phone:

________________________ ( ) _____________

Name Phone

Address (if known): _____________________________

_______________________________________________

Emergency Contact: ____________________________________ ( ) ______________________________

Name Phone

1 Health Insurance Information

Health Insurance Carrier: _____________________________________________ Phone: ( ) ______________________

Subscriber Name: ___________________________________ Your relationship to subscriber: ______________________

Subscriber SSN: _____________________ Subscriber DOB: _____________ Subscriber’s Employer: ___________________

Policy Number: ______________________ Group Number: _________________ Plan Name: ______________________

Secondary Health Insurance Carrier: _________________________________Phone: ( ) ____________________________

Subscriber Name: ________________________________Your relationship to subscriber: _____________________________

Subscriber SSN: _____________________ Subscriber DOB: _____________ Subscriber’s Employer: ___________________

Policy Number: _____________________ Group Number: ____________________ Plan Name: _______________________

Managed Care Company Name:___________________________________ Phone: ( ) ____________________________

Assignment: By my signature below, I agree to allow Arlington Psychological Services to bill my insurance company (and any secondary insurance companies or Managed Care companies) for my services there, and to thereby receive a portion of the payment due for services delivered.

_________________________________ _____/_____/_______

Signature Date

Physical Location:

305 North Olympic (enter from alley)

Arlington, WA 98223

Mailing Address:

P.O. Box 1655

Port Angeles, WA 98362

Paul C. Daley, Ph.D.

Licensed Psychologist (#913)

Telephone: 425-345-9351

Fax: 1-360-457-4347

Email: paps@

pcd@

Physical Location:

305 North Olympic (enter from alley)

Arlington, WA 98223

Mailing Address:

P.O. Box 1655

Port Angeles, WA 98362

Paul C. Daley, Ph.D.

Licensed Psychologist (#913)

Telephone: 425-345-9351

Fax: 1-360-457-4347

Email: paps@

pcd@

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