ROBERT S. MILLER, LICSW, ACSW, PLLC

275 SE Cabot Drive, Suite B206

Oak Harbor, WA  98277-3755

360.240.8090

 

DISCLOSURE STATEMENT

 

This form provides you (the client) with information about the counseling practice of Robert S. Miller, LICSW, in addition to information provided in the Notice of Privacy Practices.

 

 

NATIONAL PROVIDER IDENTIFIER:  1477557338

 

LICENSURE: I am a Licensed Independent Clinical Social Worker (#LW00005444) in Washington State.

 

MY EDUCATION & TRAINING: 

 

BA          Sociology, Seattle Pacific University, 1970

AM         Social Work, The School of Social Service Administration, University of Chicago, 1972

 

I have completed continuing education courses on topics that include Attachment, Atten­tion Deficit Dis­order and Attention-Deficit/Hyperactivity Disorder, Bipolar disorder, depression, grief, the Health Insurance Portability and Accountability Act (HIPAA), in­fant mental health, Posttraumatic stress and other trauma disorders, principles of documentation, professional ethics, psychiatric hospital surveys, Schizophrenia and numerous other mental health topics.

 

Experience:  Thirty-five years experience, including three years in child wel­fare services, and eighteen years in general community mental health practice: individual counseling with children, adolescents, and adults; couples counseling; and family counseling. 

 

I meet Washington State requirements as a Mental Health Profes­sional [per RCW 71.05.020(21)] and Children’s Mental Health Specialist [per RCW 71.34.020(2)].  I have 11 years experience in evaluating and providing brief counseling to per­sons with Attention Deficit Disor­ders (ADD/ADHD) and other disruptive behavior disorders.

 

Professional Memberships:  I am a member of the National Association of Social Workers (NASW) and the Academy of Certified Social Workers (ACSW). 

 

CONFIDENTIALITY: 

 

When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; and where a client presents a danger to self, to others, to property, or is gravely disabled (for more details see also the HIPAA Notice of Privacy Practices).  I am not required to treat as confidential a communication that reveals the contemplation or commission of a crime or harmful act.

 

When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding.  If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by me.  In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members.  I will use my clinical judgment when revealing such information.  I will not release records to any outside party unless I am authorized to do so by all adult family members who were part of the treatment.

 

Emergencies:  If there is an emergency during our work together, or in the future after termination, when I become concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care.  For this purpose, I may also contact the person whose name you have provided on the biographical face sheet.

 

Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims.  If you so instruct me, only the minimum necessary information will be communicated to the carrier. Unless authorized by you explicitly, the Psychotherapy Notes will not be disclosed to your insurance carrier.  I have no control or knowledge over what insurance companies do with the information I submit or who has access to this information.  You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance.  The risk stems from the fact that mental health information is entered into insurance companies’ computers and soon will also be reported to the, congress-approved, National Medical Data Bank. 

 

Confidentiality of E-mail, Cell Phone and Faxes Communication: It is very important to be aware that e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence, the privacy and confidentiality of such communication can be compromised.  E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them.  Faxes can easily be sent erroneously to the wrong fax number.  Please notify me at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices.  Please do not use e-mail or faxes for emergencies.

 

Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

 

Consultation: I consult regularly with other licensed counseling professionals regarding my clients; however, the client’s name or other identifying information is never mentioned.  The client’s identity remains completely anonymous, and confidentiality is fully maintained.

 

*    Considering all of the above exclusions, if it is still appropriate, upon your request, I will release information to any agency/person you specify unless I conclude that releasing such information might be harmful in any way.

 

EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my answering machine (360.240.8090) and your call will be returned as soon as possible.  In an emergency, after hours or on weekends, you can call me at (360) 929.5087.  I check my messages several times a daily, unless I am out of town.  If an emergency situation arises, please indicate it clearly in your message.  If you are suicidal or are having thoughts of harming another person, you should call 911 or go to the nearest hospital emergency room immediately.

 

PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the standard fee of $150.00 for the initial intake session and $100.00 thereafter per 50-minute session at the end of each session or at the end of the month unless other arrangements have been made.  Telephone conversations, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. may be charged at the $100.00 hourly rate, unless indicated and agreed otherwise.  Please notify me if any problem arises during the course of therapy regarding your ability to make timely payments.  Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies.  Not all issues/conditions/problems, which are the focus of psychotherapy, are reimbursed by insurance companies.  It is your responsibility to verify the specifics of your coverage.  I accept the following credit cards:  VISA, MasterCard, American Express and Discover.

 

I reserve the right to add a 1% finance charge on overdue balances after 60 days, and the right to send overdue bills to a collection agency after 90 days of non-payment

 

CANCELLATION:  Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours (one day) notice is required for re-scheduling or canceling an appointment.  Unless we reach a different agreement, the full fee may be charged for sessions missed without such notification.  Most insurance companies do not reimburse for missed sessions.

 

MEDIATION & ARBITRATION: All unresolved disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration.  The mediator shall be a neutral third party chosen by agreement of me and the client.  The cost of such mediation, if any, shall be split equally, unless otherwise agreed.  In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Island County, Washington, in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed.  Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, I can use legal means (court, collection agency, etc.) to obtain payment.  The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees.  In the case of arbitration, the arbitrator will determine that sum.

 

THE PROCESS OF THERAPY/EVALUATION: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy.  Working toward these benefits; however, requires effort on your part.  Psychotherapy requires your active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior.  I will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy, and will expect you to respond openly and honestly.  Sometimes more than one approach can be helpful in dealing with a certain situation.  During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, anxiety, depression, fear, insomnia, sadness, worry, etc.  I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed.  Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. 

 

Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships.  Sometimes a decision that is positive for one family member is viewed quite negatively by another family member.  Change will sometimes be easy and swift, but more often it will be slow and even frustrating.  There is no guarantee that psychotherapy will yield positive or intended results. 

 

During the course of therapy, I will likely to draw on various theoretical counseling approaches according, in part, to the problem that is being treated and his assessment of what will best benefit you.  My counseling methods and techniques are influenced by the three types of therapy listed below, and an understanding of newly emerging research findings on neurobiological disorders: 

 

1.     Cognitive-Behavioral Therapy challenges a client’s incorrect thinking process.  The basic prem­ise of this ap­proach is that thoughts about a particular event result in feelings, which in turn lead to behavioral responses.  Thus, faulty percep­tions and in­terpretations of an event may cause mal­adaptive responses.  The therapist helps the client change faulty ways of thinking that progress to self-defeating feelings and poor behavioral choices.

 

2.     Problem-Solving Therapy focuses on the family unit, emphasiz­ing the social context of human problems.   The goal of ther­apy is to “solve problems, achieve goals, and change the patient’s behavior.”

 

3.     Reality Therapy postulates that people need to feel loved and esteemed.  This approach helps cli­ents meet their needs by teaching them to make responsible choices.  It is concrete and present-focused.  The positive relation­ship be­tween the therapist and client is key to successful treatment.  Therapists praise responsible behavior and dissuade irrespon­si­ble behavior.

 

Remember: as a consumer, you have the right to choose a therapist and treatment modality that best suits your needs.  You have the right to refuse treatment.

 

Discussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment, I will discuss with you (client) my working understanding of the problem, treatment plan, therapeutic objectives, and I view of the possible outcomes of treatment.  If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, my expertise in employing them, or about the treatment plan, please ask and you will be answered fully.  You also have the right to ask about other treatments for your condition and their risks and benefits.  If you could benefit from any treatment that I do not provide, I have an ethical obligation to assist you in obtaining those treatments.

 

Termination:  As set forth above, after the first couple of meetings, I will assess if I can be of benefit to you.  I do not accept clients who, in my opinion, I cannot help.  In such a case, I will give you a number of referrals that you can contact.  If at any point during psychotherapy, I assess that I am not effective in helping you reach the therapeutic goals, I am obliged to discuss it with you and, if appropriate, to terminate treatment.  In such a case, I would give you a number of referrals that may be of help to you.  If you request it and authorize it in writing, I will talk to the psychotherapist of your choice in order to help with the transition.  If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and, if I has your written consent, I will provide her or him with the essential information needed.  You have the right to terminate therapy at any time.  If you choose to do so, I will offer to provide you with names of other qualified professionals whose services you might prefer.

 

Dual Relationships: Not all dual relationships are unethical or avoidable.  Therapy should never involve a dual relationship that impairs a therapist’s objectivity, clinical judgment, or therapeutic effectiveness or can be exploitative in nature.  I assess carefully before entering into non-exploitative dual relationships with clients.  Whidbey Island is a small community and many clients know each other.  We may inadvertently meet out in the community.  I never acknowledge working therapeutically with anyone without his/her written permission.  I will discuss with you the complexities, potential benefits, and difficulties that may be involved in such relationships.  Dual or multiple relationships may detract from therapeutic effectiveness, but it is impossible to know that ahead of time.  If we enter into a dual relationship, it is your responsibility to communicate to me if the dual relationship becomes uncomfortable for you in any way.  I will always listen carefully and respond accordingly to your feedback.  I will discontinue the dual relationship if I find it interfering with the effectiveness of the therapeutic process or your welfare and, of course, you can do the same at any time.

 

UNPROFESSIONAL CONDUCT:  The purpose of the Counselor Credentialing Act is to regulate counselors is:  (1) To provide protection for public health and safety; and (2) To empower the citizens of the State of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct.

 

You should know that the following acts are considered to be unprofessional conduct in Washington State (RCW 18.130.180):

 

1.     The commission of any act involving moral turpitude, dishonesty, or corruption relat­ing to the practice of counsel­ing.

2.     Misrepresentation or concealment of a material fact in obtaining a license or in rein­statement thereof.

3.     False, fraudulent, or misleading advertising.

4.     Incompetence, negligence, or malpractice which results in injury to a patient or which creates an unreasonable risk that a patient may be harmed.

5.     Suspension, revocation, or restriction of the individual's license to practice counseling.

6.     The possession, use, prescription for use, or distribution of con­trolled substances or legend drugs in any way other than for legitimate or therapeutic purposes.

7.     Violation of any state or federal statute or administrative rule regulating the pro­fession of counseling.

8.     Failure to cooperate with the disciplining authority.

9.     Failure to comply with an order issued by the disciplining author­ity.

10.  Aiding or abetting an unlicensed person to practice when a license is required.

11.  Violations of rules established by any health agency.

12.  Practice beyond the scope of practice as defined by law or rule.

13.  Misrepresentation or fraud in any aspect of the conduct of the business or profes­sion.

14.  Failure to adequately supervise auxiliary staff to the extent that the consumer's health or safety is at risk.

15.  Engaging in a profession involving contact with the public while suffering from a contagious or infectious disease in­volving serious risk to public health.

16.  Promotion for personal gain of any unnecessary or inefficacious drug, device, treat­ment, procedure, or service.

17.  Conviction of any gross misdemeanor or felony relating to the practice of the per­son's profession.

18.  The procuring, or aiding or abetting in procuring, a criminal abortion.

19.  The offering, undertaking, or agreeing to cure or treat disease by a secret method, procedure, treatment, or medicine, or the treating, operat­ing, or prescribing for any health condition by a method, means, or proce­dure which the licen­see refuses to divulge upon de­mand of the disciplining authority.

20.  The willful betrayal of a practitioner-patient privilege as recog­nized by law.

21.  Violation of chapter 19.68 RCW [Rebating by Practitioners of Healing Professions].

22.  Interference with an investigation or disciplinary proceeding.

23.  Current misuse of alcohol, controlled substances, or legend drugs.

24.  Abuse of a client or patient or sexual contact with a client.

25.  Acceptance of more than a nominal gratuity, hospitality, or sub­sidy offered by a rep­resentative or vendor of medical or health-related products or services intended for patients, in contemplation of a sale or for use in research publish­able in professional journals, where a conflict of interest is presented, as defined by rules of the disciplining author­ity...

 

Complaints about unprofessional conduct should be directed to the Department of Health at:

 

Health Professions Quality Assurance
PO Box 47860
Olympia WA 98501-7860
(360) 236-4700

 

I have read the above Agreement and Office Policies and General Information carefully; I understand them and agree to comply with them:

 

 

____________________________________________________________________________ Date: _____

Client’s name (print)                                           Signature

 

 

____________________________________________________________________________ Date: _____

Therapist’s Signature

 

 

 

 

 

Rev. 03/16/07