Psychotherapy Informed Consent

Washington State law guarantees that you have the right and obligation to make decisions concerning your health care. Therefore, it is important that you are informed about the services you are planning to receive through Dr. Annie Laweryson PLLC, your rights as a client, services provided by Dr. Laweryson, or the policies outlined below.

Risks and Benefits of Psychotherapy

Receiving psychotherapy comes with both risks and benefits. The risks involve strong, uncomfortable, or unsolicited emotional reactions (e.g., intense sadness, guilt, anxiety, loneliness, helplessness, anger, or other negative emotions) that may arise before, during, or after a psychotherapy appointment. Some people recall unpleasant memories which may cause a client to feel bothered in other areas of their life. It is common for some clients to experience an increase in their problems or symptoms temporarily, after beginning psychotherapy. These risks are to be expected when trying to make changes in their life. There are multiple benefits to psychotherapy. For example, research indicates most clients receiving psychotherapy will experience some form of benefit or improvement. Although, I cannot guarantee that symptoms will diminish, decrease, or improve with psychotherapy.

Confidentiality

Washington State law and ethical guidelines require that I keep what you tell me confidential and private. This means that I will not discuss your personal or health information with anyone else unless you provide written consent for me to do so (including electronic signatures). It is important to know that I typically provide and receive ongoing consultation with other mental health and health professionals to ensure you receive the best care possible. I do not share unnecessary details about your case or your personal health information such as your name, date of birth, address, phone numbers, etc. when consulting with other professionals unless you provide written (including electronic signatures) consent for me to do so. If you request your psychotherapy records be released in whole or in part, the release of information that you sign will include information from our visits. Due to Washington State Laws, teens who are age 13 and older will be required to sign a release of information before I can share information with their parents or guardians (including information related to scheduling and treatment, etc.). Important: While state law and my professional ethics require me to protect your confidentiality and privacy there are a few situations in which your confidentiality is NOT protected. These include:

  1. You make a serious threat to harm yourself or another person. The law requires me to try to protect you or that other person which means I may have to tell others about the threat. I cannot promise never to tell others about threats you make.
  2. If I believe a child, vulnerable/dependent adult, or elderly person has been or will be sexually, physically, emotionally abused or neglected, I am legally required to report this to the authorities.
  3. If you were sent to me by a court for evaluation or treatment or are involved in litigation, the court may expect a report from me. I may then be ordered to show the court my records.

Additional Policies:

Please be aware the following policies are subject to change.

Payment

Full payment for services rendered is due at the time of service. The session fee for an individual 53-minute session is $225. This rate is subject to change at the determination of Dr. Annie Laweryson, PLLC. Typically, rates are raised annually, in accordance with local and national inflation. However, I reserve the right to change or adjust these rates at any time, prior to services received. If you are an established client, I will make efforts but cannot guarantee at least three months’ written or verbal notice, prior to rate adjustment. Prior to your first session you will complete a Payment Authorization Form. This information will be kept on file through the Therapy Notes Portal which is a secure, HIPAA compliant platform. This information will be used to process your payment for services rendered as well as cancellation/no-show fees.

Late Fee and Cancellations

Sessions lasting longer than 60 minutes will be charged an additional $46.25 per 15 minutes. If you show up late to the session we will still end at the same time, and you will be charged the full session fee. If you do not provide at least 24 hours’ notice to cancel your session you will be charged a no-show fee of $100. If for some reason I am late to a session or need to cancel I will make efforts to adjust the session time accordingly (e.g., adding the missed time at the end of the session) or reschedule the session at the next available opportunity, whichever is more convenient to you.

Therapy Notes Platform

Before your first session you will need to create a client portal via Therapy Notes. This portal is HIPAA compliant and secure. It is meant for your access only so please do not share your information such as usernames or passwords. After you create a client portal in Therapy Notes, you will need to review and sign the Informed Consent and Policies, Notice of Privacy Practices, Payment Authorization, Client History, Client Contact, and Release of Information (if necessary). These forms will be emailed to you after the initial phone call.

Communications

You can use the Therapy Notes portal or call me at (509) 669-6587 to schedule, cancel, and reschedule your appointments. If you need to get ahold of me for any other reason you can call me and leave a voicemail. To protect your privacy, I recommend only leaving your name and phone number and I will know to call you back. I typically respond in 1 business day; however, this may not always be possible. Please know that my practice email is not monitored and although I take precautions, I cannot guarantee confidentiality. For this reason, email will only be used for initial communications or scheduling purposes. Please do not share your personal health information, other details about yourself, or attachments over email.

COVID19

Due to the on-going world pandemic, I require all clients who wish to meet in person to be fully vaccinated with the COVID19 vaccine. Please know that I am fully vaccinated myself and am committed to keeping up with health recommendations and guidelines outlined by the State, CDC, and WHO. Currently, I require all individuals to wear a face mask when receiving services in-person. Please be mindful and always wear your mask when in the building. I understand that some folks are not able to follow vaccine and/or mask regulations. If you are one of these individuals, I am available to meet with you over the telehealth.

Privacy Practice Notice

Your Information. Your Rights.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this document carefully.

You have the right to:

  • Get a copy of your paper or electronic medical record
  • Correct your paper or electronic medical record
  • Request confidential communication
  • Ask us to limit the information we share
  • Get a list of those with whom we’ve shared your information
  • Get a copy of this privacy notice
  • Choose someone to act for you
  • File a complaint if you believe your privacy rights have been violated

Your information may be used to:

  • Treat you
  • Run the organization
  • Bill for services
  • Help with public health and safety issues
  • Do research
  • Comply with the law
  • Respond to organ and tissue donation requests
  • Work with a medical examiner or funeral director
  • Address workers’ compensation, law enforcement, and other government requests
  • Respond to lawsuits and legal actions

Know Your Rights

This section explains your rights and some of our responsibilities to help you. When it comes to your health information, you have the right to:

Get an electronic or paper copy of your medical record

  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you.
  • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
  • We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

  • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you

  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

  • You can complain if you feel we have violated your rights by contacting us using the information on page 1.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints/.
  • We will not retaliate against you for filing a complaint.

Know Your Choices

For certain health information, you can tell us your choices about what we share. 

If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases, we never share your information unless you give us written permission:

  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

We typically use or share your health information in the following ways:

Treat you: we can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. Run our organization: we can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. Bill for your services: we can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues: we can share health information about you for certain situations such as:

  • Preventing disease
  • Helping with product recalls
  • Reporting adverse reactions to medications
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to anyone’s health or safety

Do research: we can use or share your information for health research. Comply with the law: we will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests: we can share health information about you with organ procurement organizations. Work with a medical examiner or funeral director: we can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers’ compensation, law enforcement, and other government requests: we can use or share health information about you:

  • For workers’ compensation claims
  • For law enforcement purposes or with a law enforcement official
  • With health oversight agencies for activities authorized by law
  • For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions: we can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Notice effective 9/24/2021

It is important to acknowledge that Dr. Annie Laweryson, PLLC runs and operates on the traditional homelands of the Puyallup Tribe. We acknowledge the significance of this land as well as the ongoing stewardship provided by the Puyallup and Salish People. We are committed to promoting, uplifting, and honoring the voices of the Coast Salish People as well as other Indigenous People, especially within the field of psychology.

Copyright © 2021 Dr. Annie Laweryson, PLLC- All Rights Reserved, Privacy Policy