Disclosure Statement

Individuals, couples and families - Providing a “Healing Place” for persons on their journey to wholeness

Dear Clients,

Welcome to Healing Places Counseling Center (HPCC).  We are pleased that you have chosen our services.  In order to inform you about our policies, your rights as a client, and your counselor's background, we have provided the following information. Please read this material carefully and ask your counselor for clarification if needed.

The mission of HPCC is to provide professional counseling and training in the tradition of pastoral care.  We are a community of professionals who view our work as ministry, integrating spiritual principles and traditions with contemporary psychotherapy and behavioral science.

Office Policies

Fees:  Our fees for counseling are $200 for the initial session and $150.00 per session thereafter.  If you are unable to pay this fee, we have resources to help. Please discuss this with your counselor. 

Payment:  Clients are expected to pay their counselor at each session, unless other arrangements are made. Please make checks payable to Healing Places Counseling Center (HPCC). We are unable to accept Medical Coupons.  A twenty-five dollar ($25.00) charge will be made for checks that are returned for any reason.

Insurance:  If you are using insurance as a resource to pay for counseling, you will be responsible for paying your fee unless you assign (request) insurance benefits payable to HPCC.  When benefits are paid directly to HPCC, then you are responsible for paying your portion (or co-payment) at each session, including your insurance deductible.

Appointments:  Counseling sessions are 50 minutes, unless otherwise arranged. Consistency in keeping appointments is important to the counseling process. If you are unable to keep an appointment, you must give 24 hours notice or you will be charged your contracted fee (not just your co-pay amount if using insurance) for the missed session. Please initial here to signify your understanding and acceptance of this policy. __________

Contact us:  You may contact Healing Places at (253) 564-4233 and leave a message on the Voice Mail.  Your call will be returned as soon as possible. Each counselor also has a voice mail number, which you may call to leave messages.  Please ask your counselor for his or her voice mail number. Your calls will be returned when your counselor is available.

Emergencies:  HPCC does not provide direct emergency service. If you have a life threatening emergency, call "911".  For non-life threatening crises, call the crisis line: 1-800-576-7764 or 253-396-5180 or Crisis Triage at 253-396-5228.

Telephone Calls:  If you request a call from your counselor which requires a toll (long distance) call, you will be charged for calls over five minutes.  Your counselor may also charge you for his or her time. Please discuss these arrangements with your counselor.

Interns:  Part of the mission of HPCC is to train professional counselors. If you are working with an intern, please be assured that s/he has received ample training and is presently under intensive supervision.

Your Rights as a Client

Choice of counselor:  Counselors vary in their approach to counseling. You have a right to choose a counselor who suits your needs.  If you have concerns over the suitability of your counseling, please discuss this with your counselor. If an understanding cannot be reached, s/he can help you arrange for an appropriate referral. When you choose to end counseling, it is of therapeutic value to work through the transition with your counselor so that issues of concern have been addressed.

Counselors practicing counseling for a fee must be registered or licensed with the department of health for the protection of the public health and safety. Registration of an individual with the department does not include a recognition of any practice standards, nor necessarily imply the effectiveness of any treatment.  (WAC 246-810-031)

Confidentiality:  All issues discussed during counseling sessions are confidential. We do not release information without your written permission, except under the following circumstances:

A. As required by law (RCW 70.02.050):
  1) when there is threat or risk of self harm (suicide), or harm to another person (homicide).
  2) when there is "reasonable cause" to suspect abuse or neglect of a child, disabled or elderly
    person, from anything reported in a counseling session.
  3) when we receive a subpoena issued from a judge or court.

B. Professional consultation:  As part of our professional responsibility we consult regularly with colleagues on the HPCC staff, and may also receive clinical supervision from qualified supervisors outside of the HPCC staff.

C. Insurance:  If you are using insurance, be advised that your insurance company may require us to disclose confidential information.
Please discuss with your counselor any questions or concerns you may have about these exceptions.

Records:  We keep a record of the health care services we provide you. You may ask us to see and copy that record. You may also ask us to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. To obtain more information about the procedures pertaining to the disclosure of your record, or seeing your record, please contact your counselor or the HPCC business office.  (RCW 70.02.120)

Contract for Counseling Services

To be completed and signed during session with counselor

I have received a copy of this document and by my signature understand and agree to the policies contained herein.

Download a printable disclosure statement (PDF)


Client (Parent or legal guardian, if client is under 18)   Date

Client   Date

Counselor   Date


Upon beginning counseling, you and your therapist will sign this document to establish a contract for services.
Also upon beginning of counseling, all clients receive a Personal Disclosure Statement from their therapist and a disclosure statement that reveals important information from the Federal Government's Health Insurance Portability and Accountability Act (HIPAA).