Informed Consent & Disclosure for Clinical Services 

Kerri Codville MA LMFT

Neptune Counseling PLLC
12812 3rd Ave SE Suite A 

Everett, WA 98208
License #LF61388461

NPI# 1124668397

EIN #33 1307655

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by signing at the end of this document.

THE THERAPEUTIC PROCESS

To ask for and receive support is a courageous and kind act. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety; as well as deep understanding and feelings of acceptance and comfort. Making changes in your beliefs or behaviors can be scary and sometimes disruptive to the relationships you already have. As we engage in the therapeutic process you have the right to ask questions about, disagree with, or refuse anything that happens in therapy. Therapy is about bending, not breaking. While we will go at your own pace, I will also provide opportunities for you to challenge yourself and your edges. I will be curious, present, and focused on creating a safe space for you as we navigate the unknown together. I am passionate about supporting your individuality as you journey towards personal growth, clarity, and a deeper understanding. This is a collaborative experience, and you are always welcome to ask me why I’m doing something in particular or to try something that you think will be helpful. The space we create in therapy is an opportunity for you to commit to your goals of growth and healing and while I hope you will commit to this process, you have the freedom to end therapy whenever you would like.

I am not able to propose an appropriate diagnosis or course of treatment for you until we have spent some time together. As soon as I am able to identify a diagnosis and an appropriate course of treatment, I will openly discuss it with you.

EDUCATION & QUALIFICATIONS


I am a  Marriage and Family Therapist licensed by the State of Washington. My credential number is LF61388461.


I received my Master of Arts in Marriage and Family Counseling from Antioch University Seattle and my Bachelor of Science in Psychiatric Nursing from Douglas College. I completed my clinical internship at Northshore Youth and Family Therapy. My professional background is in Psychiatric Nursing.


I regularly participate in training, workshops, conferences, and consultations to further develop my skills and growth as a clinician. I have received advanced training and mentorship in depth psychology, British Object Relations theory, and EMDR. I specialize in working with trauma, abuse, anxiety, and attachment issues. 



THERAPEUTIC ORIENTATION


I  am a creative with a curious spirit, passion for learning, and a heart for gathering and developing people.  In my therapeutic practice I am dynamic and collaborative. Together we will create space to deepen your connection to your inner world, give meaning to past experiences, transform thinking patterns, and explore new styles of being and relating. I am dedicated to being a strong, consistent, warm, and honest sojourner on your journey toward a freer and more satisfying way of living and being.

I am a depth psychotherapist and my approach is informed by relational psychodynamic theory, attachment theory, systems theory, dialectical behavioral therapy (DBT), narrative therapy, emotionally focused therapy (EFT), structural family therapy and EMDR.

I utilize somatic and trauma-informed practices and I work from a social justice framework.



SUPERVISION & CONSULTATION

I also seek on-going consultation from other experienced therapists as part of my desire to bring you the best possible care. When doing so, I will protect your privacy and omit any identifying information.  


ACCESS TO RECORDS


I have an agreement with Shelterwood Collective, PLLC to serve as my records custodian. They have access to my client files, in accordance with all applicable state and federal laws or rules, in order to make appropriate notification and referrals in case I am temporarily or permanently incapacitated. If you do not consent to Shelterwood Collective accessing your file in case of my incapacity, please let me know so that I may make alternative arrangements.


COMMUNICATION & EMAIL

It is my policy to use email for scheduling, financial arrangements, and to check in if I have not heard from you as expected. Because of the nature of electronic communications, I cannot guarantee the confidentiality of information transmitted via email. Please know that emails may become part of your legal file if the court were to request records.

YOUR RIGHTS AS A CLIENT

This is your space. I invite you to bring any and all questions, concerns or frustrations you may have during the course of therapy. If you would like something different in our time together, please bring it forward and I will work with you to create a space in which you feel comfortable and in which your needs and preferences are better met. I will likely make observations and suggestions, and provide feedback. I will periodically check in with you about how you feel about the work we are doing.

You have the freedom to make decisions as you please. You have the right to refuse any treatment you do not want, and the responsibility to choose a provider and treatment modality which best suits your needs. You may generally engage in therapy for as long as you like. You may, at any time, change your goals for therapy, and/or you may choose to end our relationship, no matter where you are in the process of goal achievement. I respect and promote your right to make your own decisions. I believe doing so is part of the healing process in therapy. Should it become apparent that I am not able to meet your needs in counseling, I will readily provide you with referrals to other therapists.

You have the right to a relatively comfortable, safe, and professional environment where I consider your best interests my priority. Professional boundaries are essential so that no harm or damage is done. I maintain the following practices regarding professional relationship boundaries:

  • I will not, at any time, have a social relationship with you outside of my office, even after we have ended our therapeutic relationship. This is a professional boundary, not one of not caring.

  • In this same vein, I will not accept social network follow requests.

  • I will not, at any time, have personal physical or sexual contact with you.

  • I will not, at any time, accept any gifts from you.

  • If I were to see you in public at any time, I will not initiate any contact with you, out of respect for your confidentiality. If you initiate, I will respond in kind, but no further than you offer.

YOU HAVE THE RIGHT TO CONFIDENTIALITY

I am bound by law and professional ethics to protect client rights to confidential communications regarding their involvement in counseling. All issues discussed in the course of counseling are strictly confidential. You do not have the responsibility to maintain confidentiality and are free to discuss your therapy with anyone you wish.

Your participation in therapy, the content of our sessions, and any information you provide to me is protected by legal confidentiality.  Some exceptions to confidentiality are the following situations in which I may choose to, or be required to, disclose this information:

  • If you give me written consent to have the information released to another party;

  • With your authorization, to effect billing of a third-party payor for the services I provide to you;

  • In the case of your death or disability I may disclose information to your personal representative;

  • If you waive confidentiality by bringing legal action against me;

  • In response to a valid subpoena from a court or from the secretary of the Washington State Department of Health for records related to a complaint, report, or investigation;

  • If I reasonably believe that disclosure of confidential information will avoid or minimize an imminent danger to your health or safety or the health or safety of any other person;

  • If, without prior written agreement, no payment for services has been received after 90 days, the account name and amount may be submitted to a collection agency.

As a mandated reporter, I am required by law to disclose certain confidential information including suspected abuse or neglect of children under RCW 26.44, suspected abuse or neglect of vulnerable adults under RCW 74.34, or as otherwise required in proceedings under RCW 71.05.

GROUP COUNSELING

If you are participating in group counseling, it is important you understand that I will adhere to the ethical and legal requirements of confidentiality.  However, I cannot ensure that the other group counseling participants will maintain confidentiality about your therapeutic experience including content discussed within the group counseling session.

FAMILY AND RELATIONSHIP COUNSELING

If you are seeking family or relationship counseling, it is important you understand that I will adhere to the ethical and legal requirements of confidentiality, however, I cannot ensure that you or the other participants in the family or relationship counseling will maintain confidentiality about your therapeutic experience including content discussed within the counseling session. In addition, in the case of family or relationship counseling, the entire treatment record will be available to any and all participants in the family or relationship counseling, and all participants must consent to any authorized third party disclosure.

I cannot maintain secrets between members of the family or relationship. In such situations, if we cannot find a clinically appropriate way for you to disclose the information to the other member(s) of the family or relationship, I may need to terminate the clinical relationship and refer you to another provider. 

WORKING WITH MINORS

If you are the parent or guardian of a minor who is seeking treatment, please know that under Washington State law, any child age 13 or older can independently consent to mental health treatment without your permission. In addition, parents or guardians may not generally access the treatment record of a client aged 13 or older without that client’s written permission. If you are 13 years of age or older, you have the legal right to seek mental health treatment without obtaining permission from a parent or guardian. Under certain circumstances, the parent of an adolescent may consent, on behalf of the adolescent, to a mental health or substance use assessment and limited treatment.

I am not able to provide a recommendation, evaluation, or opinion, in any legal forum relating to separation, divorce, child custody, visitation, or parenting plans. I will need to be provided with a copy of any parenting plan, custody orders, or any other similar documents, including any changes or revisions made during the course of treatment.  It is generally necessary that both parents or legal guardians consent to treatment of their minor child.

COMPLAINTS

If you have any concerns about your experience or if you believe that I have acted in an unprofessional or unethical manner, I encourage you to let me know so that we may discuss the situation and I can have the opportunity to address or resolve the problem. A copy of the Washington Acts of Unprofessional Conduct can be found in RCW 18.130.180. If you think that discussion has not worked or if you feel uncomfortable bringing this directly to me, for any reason, you are encouraged to contact the Department of Health:

Health Professions Quality Assurance PO Box 47869, Olympia, Washington, 98504
Email: HSQAComplaintIntake@doh.wa.gov / Phone: (360) 236-4700

YOUR RESPONSIBILITIES AS A CLIENT

SCHEDULING

Consistency is integral to the therapeutic process. We will work together to find a consistent time to meet each week. Therapy sessions are 50 minutes. If you arrive late to a session, you will be seen for the remaining time and will be charged the full fee we have agreed upon.

FEES & BILLING POLICIES

You are agreeing to begin a therapeutic relationship, which involves the following financial responsibilities.

The cost of psychotherapy is determined by the length of session. My fees are as follows:

  • 50-minute psychotherapy session — $160 (90837)

  • 50-minute intake session — $200 (90791)

  • 50-minute relationship session — $180 (90847)

  • 80-minute relationship session — $260 


I provide psychotherapy in person and via telehealth. The cost for either format is the same, based on the session length and type outlined above.

I work with clients on a weekly cadence. The frequency of sessions may be more or less than once per week, depending on your clinical needs.

Payment is due at the beginning of each session. I receive payment via check or debit/credit card.

I do not voluntarily participate in legal proceedings. If my participation is requested or required in a legal matter, the regular hourly rate applies to all preparation, participation, travel, and waiting times.

Services are expected to be provided generally on a weekly basis until treatment is terminated. Additional services may be recommended. This estimate of your costs is only an estimate, and your actual charges may differ. You have the right to initiate the patient–provider dispute resolution process if the charges you are actually billed substantially exceed the expected charges in this estimate. This estimate of costs is not a contract and does not obligate you to obtain clinical services from me.

ATTENDANCE

Since this time is reserved for you, it becomes your financial responsibility. A cancellation fee of $100 is collected for missed or canceled sessions, unless we have arranged in previous sessions that you will not attend on a particular date. In the rare case of emergencies (i.e. medical or weather-related cancellations), you will not be charged for the session. A 24-hours notice of cancellation is required. If 24-hours notice is not given and I do not have other session time available to reschedule your session in the same week, you will be expected to pay for the session.

BILLING ADMINISTRATION

I am an independent practitioner working in association with Shelterwood Collective, PLLC. All Shelterwood Collective practitioners are independent provider businesses who are solely responsible for the clinical services they provide. All services rendered are representative of each individual practitioner’s license, independent business, and practice style. We share values, resources, and community in the spirit of providing ethical, professional healing services.

INSURANCE [IN NETWORK]

I am an affiliate of Shelterwood Collective PLLC (TIN #47-4860247 / NPI-2 #1538663604). Through their group contracts I provide in-network mental health care with Premera, Lifewise, Regence, Blue Cross, Blue Shield, Kaiser PPO, and First Choice.

Insurance companies and other third-party payers may require that I provide them with information regarding the services I provide to you. This information may include the type of service provided, the dates and times of service, your diagnosis, treatment plan, a description of impairment, progress of therapy, and case notes and summaries. If you do not want me to provide your confidential information to your insurance company, let me know so that we can discuss alternatives.


You remain ultimately responsible for paying any deductible, copay, or other out of pocket expenses that your insurance provider may require.  You also remain ultimately responsible for paying any claims that your insurance provider may reject.


INSURANCE [OUT OF NETWORK]


In order to be reimbursed for services, insurance companies and other third-party payers may require that I provide them with information regarding the services I provide to you. This information may include the type of service provided, the dates and times of service, your diagnosis, treatment plan, a description of impairment, progress of therapy, and case notes and summaries. If you do not want me to provide your confidential information to your insurance company, let me know so that we can discuss alternatives.

COMPLETION OR TERMINATION OF THERAPY

When you would like to end therapy, I encourage you to discuss this in session. I believe that spending time to process an ending can be helpful and healing, as well as uncomfortable and easy to avoid. For this reason, I strongly suggest taking 1-3 sessions to complete your therapy. You have the right, at any time in the therapeutic process, to ask for a change of direction or to discontinue. If I don’t hear from you for 30 days, I will assume you aren’t coming back and will terminate the current episode of care.

EMERGENCIES

I provide non-emergency clinical services by scheduled appointment.  If you are in a crisis or an emergency situation, please call 911 or go to your nearest emergency room. You may also contact King County’s Crisis Connections at 206-461-3222 or 1-866-427-4747.

CLIENT ATTESTATION & CONSENT FOR SERVICES

By signing this document, you are attesting that you have received, read, fully understand and consent to the disclosures, terms, and conditions above, that you have received a copy of your HIPAA Notice of Privacy Practices, have read and fully understand these rights, and have been given the opportunity to ask questions.

By signing this document, you are attesting to your consent to participation in counseling services provided by Kerri Codville, MA, LMFT.