STACEY McFARLAND, LICSW, BCD
STACEY McFARLAND, MSW, LICSW, BCD1000 Second Avenue, Suite 1320SEATTLE, WA, 98104Telephone (206) 369-1368State of Washington Required DisclosureThis disclosure statement provides information about the treatment provider and the treatment offered to assist the client in choosing the treatment and the provider best suited to your needs.Therapist’s Approach to Treatment, including Methods and TechniquesMy approach to treatment is informed by psychodynamic theory, depth psychology and cognitive behavioral therapy. Our work together in psychotherapy involves exploring thoughts, feelings, patterns in your family of origin, and life patterns you have maintained separate from your family. This process allows me to listen, observe, and help you integrate unconscious meanings and conscious thoughts. The purpose of the relationship between the therapist and client is based on developing a better understanding of your personality leading to increased self-awareness, personal growth, and more contentment in work, play and relationships. It is my aim that treatment be a collaborative effort between client(s) and therapist. To this end, I encourage you to identify areas of concern and to participate in developing treatment goals that are specific to your situation. Therapist’s Education, Training and ExperienceI am a state licensed clinical social worker (#LW00004202), as well as a Board Certified Diplomate in clinical social work. Following completion of a master’s degree in social work from the University of Washington in 1996, I completed studies in the Certificate Program in Psychodynamic Psychotherapy and took training in the Psychodynamic Psychotherapy Program at the Seattle Psychoanalytic Society and Institute. Additionally, I have worked extensively in the field of geriatric mental health, including earning the designation of Geriatric Mental Health Specialist in 1992. I have worked in the mental health field since 1990, practicing psychotherapy exclusively since 1999. I am a solo practitioner in private practice working with individuals. I am a member of the Clinical Social Work Association, the Washington State Society for Clinical Social Work, the Northwest Alliance for Psychoanalytic Study.Client’s Course of TreatmentIf you decide to continue treatment beyond the initial assessment, I will develop an individualized treatment plan with you. This plan will include what is known at the time about your course of treatment and will be amended as appropriate during our work together. The length of time you would be in treatment cannot be known early on. Counseling is understood to be a choice you’ve made among available options. Other options include: Receiving therapy from another counselor, using other therapies, using support groups, seeking self-help resources, and other modes of treatment.Risks and BenefitsCounseling can have benefits and risks. Since it often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings, such as sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, counseling has been shown to have many benefits. It often leads to better relationships, in can provide solutions to specific problems, and there is often a significant reduction in feelings of emotional distress. Some patients need only a few sessions to achieve their goals, while others may benefit from long term counseling.ConfidentialityIn addition to this document, you received my Notice of Privacy Practices, which described how I might use and disclose your health information. I am bound by my professional ethics to protect client rights to confidential communications in regard to their involvement in psychotherapy. For this reason, if you wish me to release information about your participation in therapy to anyone, I will require a signed “Release of Information” from you. There are exceptions to this confidentiality as provided by law:In the event of a threat of harm to oneself or someone else, if that threat is perceived to be serious, the proper individuals must be contacted. This may include the individual against whom a threat is made. This may also include knowledge that a patient is HIV positive but unwilling to inform others with whom he/she is intimately involvedIn the event of suspected abuse of a child, developmentally disabled person, or a vulnerable adult the proper authorities must be contacted. The actions do not have to be witnessed to be reported.If ordered by a judge or other judicial officers, information regarding your treatment must be disclosed.If you bring a complaint against me with the WA State Dept. of Health, the minimum necessary information will be released to present the Department with a comprehensive picture.In the event the client reveals the contemplation or commission of a crime or harmful act the therapist may be released to the proper authorities. As regards your confidentiality, please note that payment by check permits bank employees to view the names of my patients in that my name will appear on your check.MinorsIf you are a patient under 18 years of age and not emancipated, your parents have the right to examine your treatment records. Since privacy in counseling is often crucial to successful progress, particularly with teenagers, it is common that I request an agreement from the parents that they consent to give up access to their child’s records. If they agree, I will provide them only with general information about your progress in treatment and your attendance at scheduled sessions. Any other communication will require your authorization, unless I feel that you are in danger or are a danger to someone else, in which case I will notify your parents of my concern. Before giving parents any information, I will discuss the matter with you, if possible, and I will do my best to handle any objections you may have.Concerns about Treatment not working or Unprofessional BehaviorYou have the right to terminate counseling at any time. Stopping therapy early may result in the return or worsening of the initial problems and symptoms. I encourage you to talk to me directly if you are dissatisfied with my services or if you want a second opinion or referral to another counselor. If you intend to discontinue therapy, please discuss it with me first. If you are concerned about my professional conduct, you may file a complaint with the Department of Health, Health Professions Quality Assurance, Customer Service Center, P.O. Box 47869, Olympia, WA 98504-7869, (360) 236-4700, hpqa.csc@doh..Therapists practicing therapy for a fee must be registered or licensed with the Department of Health for the protection of public health and safety. Registration of an individual with the Department of Health, does not include recognition of any practice standards, nor necessarily imply the effectiveness of any treatment. It is every client’s right to discontinue treatment at any time. It is the responsibility of clients to choose the provider and treatment modality which best suits their needs and purposes.Billing, Fee and Financial InformationSessions will be 55 minutes in length and I charge $160 for the initial evaluation session and $135 for each following individual or couple’s session hour. Missed appointments will be charged at $100 per session. While I do my best to minimize rate changes, from time to time I do find it necessary to increase my hourly rate. You will be notified of any rate increases no less than 30 days in advance. You are not responsible for any costs prior to being given this notice. You will receive a statement at the beginning of each month and full payment is due within 14 days. If you prefer, you may pay at the time of each session. You are responsible for your account whether or not your health insurance plan eventually pays a portion of the charges unless we have made other arrangements. I do not charge for telephone calls of 10 minutes or less. If we talk between sessions to discuss issues or concerns charges will be pro-rated on the basis of my hourly fee. The same will be true for telephone interactions with attorneys, physicians, and others on your behalf, as well as for reports and letters that you request me to write on your behalf. Accounts overdue 90 days or more will be sent for collection. AppointmentsWe will agree on specific appointment times, reserved exclusively for our sessions together. Our mutual protection of this time in important in order to preserve the integrity of our ongoing work. I will give you notice well in advance of my vacation time, typically at least 4 weeks. I expect a minimum of one week’s notice about your vacations so that you will not be charged for those missed appointments. I do not charge for occasional missed appointments when I am given at least 48 hours notice. I do charge for my time in all other instances where you miss your appointment. Health insurance companies will not pay for missed sessions, nor will they pay for telephone calls, reports, letters or interactions with attorneys and others. If appointments are missed for any reason with such frequency that it interferes with the integrity of our work, this policy will be re-examined.About InsuranceYou are responsible for payment of all treatment fees and other costs. If you have health insurance and/or a third party payer, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you may be entitled. It is very important that you find out exactly what mental health services your insurance policy covers. Your health insurance company and/or third party payer may require that I provide it with information about your diagnosis, treatment plan, and your attendance at therapy sessions. It is rare, but they may require a copy of your entire treatment record. If you are using insurance and/or a third party payer, you acknowledge this and agree to allow these disclosures.By signing below, each of us confirms this disclosure agreement to represent the agreement between us, and you confirm receiving and reading a copy, and you confirm your understanding of the information provided and agree to allow the disclosures of health information as described above. _____________________________________ ________________________________________Client Date Parent/Guardian (if applicable) Date_____________________________________ ________________________________________Client Date Stacey McFarland, MSW, BCD Date ................
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