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SARAH L. RATTRAY, Ph.D.
PSYCHOLOGIST PHONE and FAX : 206 542-6148
Medical-Dental Building Washington of Richmond Highlands License No. 1531 18532 Firlands Way N. Seattle, WA 98133-3917
PROFESSIONAL DISCLOSURE STATEMENT
Please read this Disclosure Statement, which contains your rights as a client, some Washington State Laws you should know about, some information about my training, and my office policies. I will review all of this information with you when we meet, and we will sign the Signature Page together indicating your fees and your understanding of the contents of this statement.
The Board of Psychology protects your rights as a client. You are entitled to certain specified rights under RCW 18.83:
- You have the right to refuse or discontinue treatment at any time - you have the right to be satisfied with the treatment or evaluation, request a referral, or make a complaint about a therapist. If you are not satisfied with the course of therapy talk with me about how to change therapy to best suit your needs. If this does not work you have a right to request a referral to another therapist at any time.
- You are free to choose the treatment provider and treatment modality which best suits your needs. You want to be sure that you will choose a therapist who suits your needs. You can take the responsibility to be informed and to ask questions of your therapist regarding themselves, their therapeutic approach, and your progress.
- You are entitled to confidentiality in your communications with me, with some exceptions. Information discussed between a client and a psychologist is privileged, so you are the one to choose if it can be told to others, in most cases. You will be required to sign a "Release of Information" before I communicate with anyone else about your case, or even about the fact that you have come here for counseling. There are some exceptions to the requirement for a “Release of Information,” and information can be disclosed without one as provided by law in several cases including the following:
- If there is reasonable cause to believe that a child or adult dependent or developmentally disabled person has suffered abuse or neglect, or that a vulnerable adult has suffered abuse, exploitation, neglect or abandonment, I must report it to the appropriate department within legal time limits. Whenever possible I will attempt to discuss this with you first. - If you (or your dependent child) otherwise appear to be at risk for endangering yourself or someone else, including suicidal and homicidal plans, I must take legally appropriate action, depending on the specific situation. - If you appear to be gravely disabled and unable to care for your basic needs. - If you become aware that you have AIDS or have become HIV-positive and you refuse to be under medical care, I am required to report the identities of your IV-drug using and/or sexual partners to local health-care authorities. - Consultation with other appropriately trained treatment providers as needed for managing the details of the case. - If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. - If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
- You are entitled to know about my professional training and orientation:
- I am a licensed psychologist. My Washington State psychology license number is PY1531. As required of all licensed psychologists, I have a doctoral degree from an accredited university and have passed the national written examination and the Washington State Examining Board of Psychology oral examination. - My Ph.D. was granted from the California School of Professional Psychology - Los Angeles in July, 1988. - I work with individuals and couples in therapy, using a brief, solution-focused model for specific issues. For issues that require deeper exploration I use an approach that looks at the individual in the context of past experiences within their family. I tend to use a cognitive-behavioral orientation, and with couples I tend to use the Gottman Method. - The length and frequency of treatment is best discussed with each client, and periodically reviewed together.
OFFICE POLICIES:
Appointments are scheduled in increments of 50 minutes. We may choose to schedule a single session, a session and a half (75 minutes) or a double session (100 minutes). Couples therapy is most helpful in longer sessions. For all your appointments please be sure to arrive on time. The session includes the time for scheduling our next appointment and paying for the session. Payment is required at the start of each session -- make out your check in advance whenever possible (or have cash ready).
My fee is $140 per session for therapy; for “intake” - the first session - my fee is $190. Telephone time may be billed at the same rate as therapy. The fees I charge you may be different if your insurance company and I have signed an agreement for me to accept different fees. The fees I will charge you will be included on the separate Signature Page. We will fill this out and sign it together when we meet.
If you cannot make your session for any reason, including illness, appointments must be cancelled at least 48 hours in advance. Otherwise you (not your insurance company) will be charged a late cancellation / no-show fee equal to the full fee (not the co-payment) for your session, or no less than half the fee in the case of unavoidable emergency. Your appointment time is reserved for you alone, and canceling your appointment with as much notice as possible will allow me to make the time available for another client. The fee I will charge you in the event of a cancellation will be included on the separate Signature Page. You will need to sign on the separate Signature Page that you understand this policy.
Unpaid balances, including no-shows and/or late cancellations, will be charged a re-billing fee, and finance charges will accrue.
My
practice is compliant with federal HIPAA regulations – see
additional Privacy Policy for information. Department of Health (360) 236-4928 Board of Psychology 1300 S.E. Quince Street, P.O. Box 47869 Olympia, WA 98504-7869
You can keep this Disclosure Statement and this Signature Page you will sign. If you have any questions about this information be sure to ask me when we review it.
SIGNATURE PAGE:
Fee arrangements are as follows; ask if you have any questions:
The fee for the intake (first) session is: q $190 q $140 or Your co-payment for the intake session is the full session amount or The fee for therapy (second and later) sessions is q$140 per 50 minutes or Your co-payment for therapy sessions is the full session amount or Remaining deductible you have to meet is: q N/A or The late-cancellation/no-show fee for less than 48 hours notice is the fee for the scheduled session or
The terms described in the Professional Disclosure Statement have been read and understood. Fee arrangements have been clearly made, and the late-cancellation/no show policy understood and agreed to. A signed copy of the disclosure statement has been given to me, and a copy of the signature page retained by Dr. Rattray.
O O Date Client's Name Printed
O Sarah L. Rattray, Ph.D. Client's Signature
THIRD PARTY PAYOR RELEASE
I authorize the Release of Medical Information necessary to process my claim and request payment of benefits to Dr. Rattray. If I do not pay my fee in full, I authorize payment of medical benefits to Dr. Rattray for services described on the insurance form. I hereby authorize Dr. Rattray to release all information necessary. I understand that I am responsible for payment in full of services, regardless of third party coverage -- if the third party denies coverage then I am responsible for the full fee amount.
O O Signature Date 2003-P
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