Now offering Telehealth appointments! Contact us today to discuss our Telehealth options.

Disclosure Statement / Informed Consent

This document will provide you with information about Northwest EMDR Therapy, PLLC (NW EMDR) and your rights and responsibilities as a client. It provides the information you need to give informed consent to services. Please review it, and feel free to ask questions at any time.

Introduction to providers

Please read information about each individual therapist online at www.northwestemdr.com. This will include each therapist’s relevant background and education of providers as well as their treatment modality.

You may have some assumptions about what therapy will look like, and please know each therapist is different. What was true for one, may not be true for another. If you have hopes or expectations for how your therapy will go or what it will look like, we highly encourage you to speak up about those things so your therapist can try to meet your needs effectively or inform you of the ways they work that may be different from what you experienced in the past.

Once known, your therapist will discuss treatment goals with you.

Risks and benefits to therapy

There may be risks and benefits to therapy. Risks may include but are not limited to the possibility that as you talk about difficult issues, you may feel sad, angry, or upset in other ways. Things may feel worse before they get better, and there are no guarantees as to whether your hope or expectations will be fulfilled. Benefits include but are not limited to improved relationships, communication, and problem-solving skills.

Scope of practice

The services we provide at NW EMDR Therapy are clinical. We do not perform evaluations for school performance or IQ. We do not offer evaluations for forensic purposes, to assist or provide input to a court process. We do not write letters for attorneys related to parenting fitness, visitation, or custody decisions, recommendation, or opinions. We do not provide letters for service or support animals, medical fitness, return to work, or government entitlements. We may provide facts relevant to these issues, but not conclusions that are predictive of future functioning. To do so is out of our scope of practice. If you are in need of these or other services that might be out of scope for NW EMDR, you are welcome to seek the services of other professionals who can provide what you need. Please let us know as soon as possible if you seek any of these services, so your expectations are consistent with the services we provide. 

Record of services and access to record

At NW EMDR, we keep a record of the health care services we provide to all clients. You may ask to see and copy that record. You may ask to amend the record for the purpose of accuracy and completeness. We may disagree but will indicate your request. We maintain the record for at least five (5) years following the last visit. (More on Records below.) 

Your rights and responsibilities

You have rights and responsibilities that are important for you to know that are related to your participation in therapy. You have a right to ask questions about the therapy process. You have the right and responsibility to choose a therapist and treatment modality that best suit your needs. You have the right to request access to copy the record. You have the right to request that we amend the record for purposes of accuracy and completeness. We have the right to refuse your request, and will inform you and include your request in the file. You have the right to refuse or terminate therapy at any time for any reason without any obligations, other than to pay any costs owed. You have the right to confidentiality, with limits. (See below.) 

Confidentiality and limits

You have the right to confidentiality, although there are limits to it. Some of the most common exceptions to confidentiality are that I may disclose Protected Health Information (PHI): 

  • If you disclose information that gives me reasonable cause to believe that a child or elder, disabled, or dependent person has suffered abuse or neglect, I am mandated to report it to the proper authorities. “Mandated” means I do not have a choice and must disclose information that would otherwise be protected from disclosure;
  • If I believe you pose an immediate danger to yourself or someone else, I may inform the person or the proper authorities; If I receive a subpoena and/or order from a court to release information; 
  • If you or another person makes a complaint against me to the Washington State Department of Health (DOH); 
  • I may disclose your PHI without written authorization for purposes of treatment, payment, or healthcare operations, such as to other therapists, doctors, your insurance carrier for payment or audit, or to run my business;
  • If you authorize release; 
  • If a court is deciding a child’s best interests (such as during a divorce or custody decision), a subpoena may be issued to release PHI; 
  • To protect the public health; and/or 
  • To any person if I believe that use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Access to the treatment record

In general, clients age 13+ have the right to access as well as to protect their records. If an adolescent or adult client age 13 or older requests their record in writing, the record should be provided within 15 working days.

In general, parents have the right to access their child’s record when the child is under 13. For children under 13, parents may request the record in writing. When the child is age 13 or older, however, the adolescent may exercise the right of privilege over the record and refuse parents’ access.

If the therapist believes that access to the record could cause harm to the client, the therapist may say so and refuse to provide the record. If that occurs, the client may appoint another therapist of similar or equivalent training to review the record to determine the risk of harm. 

Minors under age 13

Depending on a child’s age and developmental stage, parents are asked to understand that therapy generally works best with children when they know that information remains confidential between the child and the therapist. Depending on the child’s needs, we generally meet with parents periodically to inform them of the child’s status. We always inform parents if we believe that a child appears to be at risk of serious harm to self or others, unless we believe that doing so could be harmful to the child. 

Adolescents age 13- 17

If you are a client who is 13+ years of age, you may sign your own consent for outpatient services. You have the right to control access to your record, even to the point of maintaining privacy from your parents’ access to the record. However, if your parents are paying for your services, you must sign for Release of Information to facilitate payment. Depending on the carrier’s demands, it is possible that information that may be disclosed may include but is not limited to dates of services, diagnosis, and treatment goals. 

Consultation and supervision

If your therapist is an Associate licensee, s/he is under the supervision of Vanessa Graff. Associates meet weekly to receive supervision.

Providers often find it helpful or necessary to consult with other professionals. They may consult with other therapists or attorney(s) concerning your case. Your signature below authorizes your therapist to do so. Information about you may be shared in this context without using your name to the extent possible. Consultants are held to the rules of confidentiality. 

Electronic communication

No form of electronic communication – email, text, telephone, or teletherapy – can be 100% secure. Due to current COVID related restrictions, your therapy may take place electronically. While NW EMDR Therapy works diligently to use only HIPAA compliant resources, we cannot guarantee that the use of electronic communication will be secure. Email, phone, and text should only be used for limited communication, such as to make or confirm appointments or changes in schedule. Please do not use any of these formats for substantive communication regarding clinical issues. if you have a clinical issue that you wish to address, please make an appointment for the purpose of discussion or wait until your next session. 

Your signature below acknowledges that you understand that electronic communication may not be secure, and that you wish to communicate via those formats anyway. If you do not wish to communicate via electronic communication, please inform your therapist in writing so that s/he can arrange a reasonable alternative or transfer care to a provider who can accommodate your concerns. 

COVID

We observe the laws and guidelines applicable to COVID, including guidelines regarding masking, social distancing, and hygiene. 

Teletherapy

At this time, we are offering Teletherapy services as well as in-person services. Teletherapy is the administration of clinical services through a remote electronic device such as a computer or telephone. These may include the use of audio, video, or other electronic communications. Therapists who perform teletherapy sessions receive training to ensure compliance with the rules and regulations set forth with regards to teletherapy. Rules of confidentiality are the same for Teletherapy as for face-to-face services as described in this Disclosure. The location of services with Teletherapy is considered to be where the client is. If you are not in the State of WA, I may not be able to provide services to you, depending on the laws of the state where you are located at the time reserved for your session with me. Please always let me know if you will not be in WA when we meet. Neither client nor therapist may photograph, audio- or video record any session without the written consent of the other. Both client and therapist must inform the other if any person other than client and therapist is present in the room, such as off-screen at any time during the session, even if only temporarily. 

Teletherapy can have risks and benefits. Some of these benefits include: 

  • Improved access to mental health services directly to the patient’s home or rural areas; 
  • Help integrate behavioral health care and primary care, leading to better outcomes; 
  • Reduce the need for trips to the emergency room; 
  • Reduce delays in care; 
  • Improve continuity of care and follow-up; 
  • Reduce the need for time off work or to arrange childcare services so that clients can attend appointments that are far away; and 
  • Reduce potential transportation barriers.

Possible risks to Teletherapy may include: 

  • Face-to-face cues cannot be perceived as well as in person; 
  • Screens may distort the image;
  • Camera placement can interfere with the sense of eye contact; 
  • For people who benefit from physical proximity, the experience of being in the presence of a trusted human being may be lost; 
  • Due to technology limitations, images can freeze, client and therapist may not hear all of what is said and may need to ask each other to repeat things;
  • If connection is lost, both therapist and client must know to re-connect; 
  • Technology might fail altogether before or during the session; and 
  • Therapists cannot control the privacy of the session.

Pets

In order to keep the focus on you and your therapy, we respectfully ask that you leave your household pets at home. Even during teletherapy sessions, we ask that you keep pets out of the room unless the pet is able to lie quietly without the need for your attention or causing distraction. 

Service animals

We welcome service animals that have been trained and have the required documentation for the use of a service animal.

Touch

The therapy we provide is performed with EMDR techniques that rely on verbal communication. Please use your words to communicate your feelings without emphasis through touch or hugging, even at the end of an especially emotional or difficult session. While the therapeutic relationship can elicit intense emotions, we ask that you use words rather than touch to express them. This is to ensure that both the client and the therapist maintain the boundaries and ethical guidelines that protect this type of relationship.

Termination of services

You have a right to terminate your therapy at any time, for any reason. Some reasons to terminate therapy include poor fit between therapist and client, inability to afford services or therapist relocation. You have both the right and responsibility to choose the treatment provider and modality that best suit your needs. If you feel that your therapist or the modality being used does not meets your needs, please reach out to NW EMDR Therapy management and accommodations will be made. At no time do we want you to be working with any therapist or modality that you do not feel suits your needs. Please inform your therapist or Vanessa Graff to discuss the need for change. 

NW EMDR Therapy may also terminate services. Possible reasons to terminate might be if a client doesn’t attend session, does not pay for services, does not appear to benefit from services, does not agree with therapist’s judgment for care, lack of “fit,” or for any other reason identified by NW EMDR Therapy or its staff such as threat of harm or violence. In general, when terminating services, providers will give notice and referrals appropriate to the type of therapy that has been provided. However, if termination is due to non-payment, non-attendance, or perceived threat or violence, this statement serves as notice. 

If your case is closed for any reason, it may or may not be re-opened in the future. If your case is closed, you are still obligated to pay your balance. 

Therapist transition

Sometimes therapists leave the agency such as, for example, to start a private practice. If your therapist should leave NW EMDR, you have several options: 1) You may stay here at NW EMDR and work with another therapist. We will do everything we can to ensure a seamless transition to another therapist on staff; 2) In keeping with your right to choose the therapist you believe best suits your needs, you may continue your therapy with your current therapist, wherever they provide services; 3) You may find another therapist elsewhere at your discretion; or 4) You may terminate services altogether. If you leave NW EMDR, you may receive your record with a written request. 

Therapy and consent for couples and families 

Couples or family therapy begins with an evaluation of your relationship, past and present. We understand that because of the commitment of time and money, plus the potential impact on the couple and others, it is important to make an informed choice for a couple’s or family therapist. 

The information discussed in couples or family therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving the partners. NW EMDR Therapy or its therapists will not testify for or against either party or to provide records in a court action. 

When you attend couples or family therapy sessions, you as a couple/family are considered to be “the client” and your mental health records therefore belong to both of you and any dependents of legal age. This means that except in the circumstances above, NW EMDR Therapy will need a written consent from all members of the couple and/or family who are capable of giving consent, age 13 or older, in order to disclose any information from the record to a third party. 

Because the relationship is the main focus of couples and family therapy, both partners of a couple, or all members of a family, must be present for the session to start. It is often not in the best interest of the couple or family to distribute time unevenly between participants or to have unplanned meetings with only one partner or family member present. If one person is late in arriving or does not show for the appointment, NW EMDR Therapy reserves the right to delay the start of the session or to cancel the session if necessary. If cancellation is necessary because a partner or family member doesn’t attend without notice, the client will be billed for the session. 

Secrets

There may be times when it is appropriate to share information that is learned in an individual session (or a session with only a portion of the treatment unit present) with the entire treatment unit – that is, the family or the couple. The best judgment will be used as to whether, when, and to what extent disclosures will be made to the treatment unit, and will also, if appropriate, give the individual or smaller part of the treatment unit being seen the opportunity to make this disclosure. Thus, if you feel it necessary to talk about matters that you absolutely want shared with no one, you might want to consult an individual therapist who can treat you individually. 

This “no secrets policy” is intended to treat the patient (the couple or the family unit) by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the unit being treated. For instance, information learned in the course of an individual session may be relevant or even essential to the proper treatment of the family or couple during their therapy. The highest regard to what is in the best interest of the unit of treatment will be taken into consideration when deciding whether to share information or not. If not sharing the information is contrary to the family goals there may be a situation where therapy is terminated. The policy is intended to prevent the need for such termination. Please feel free to ask any questions you have of this policy with your therapist. 

Complaint 

If you are concerned that your therapist has acted unprofessionally, or you wish to discuss a concern related to your therapist or therapy, please feel free to speak to your therapist in session, contact your therapist in writing, or write to Vanessa Graff. We at NW EMDR will be receptive to your concerns, and will make every effort to find a solution that will be acceptable for you. If we are not able to resolve your concerns, we will be happy to provide referrals to other providers who may offer a better fit for your needs. 

You may also contact the Washington State Department of Health (DOH) to file a complaint. You may write to DOH at Health Systems Quality Assurance, Complaint Intake, P.O. Box 47857, Olympia, WA 98504-7857. You can also reach the DOH by phone at 360.236.4700, or access the site to file electronically at https://fortress.wa.gov/doh/opinio/s?s=ComplaintFormHPF 

You should know that a complaint to the DOH may result in the disclosure of your record. 

Fees and payment policies 

Session rates range from $150-$200, depending on a variety of factors, including, but not limited to your therapist and your insurance plan. Session times are 45-50 minutes. Upon request, 80 minutes sessions are available at a rate of $200. 

Sessions are between 45-50 minutes or between 80-90 minutes in length. Please keep that in mind and make every attempt to work with your therapist to end the sessions in a timely manner. Since insurance companies do not reimburse for any additional time sessions that go 5 minutes or more beyond your session will incur a fee. 

Fees for legal and court-related services 

Fees for court-related services, whether you or your attorney requests it, or if your therapist is subpoenaed, are $350.00 per hour. You will be responsible for the charges for all of your therapist’s time, including but not limited to writing letters, attending deposition or trial, travel time, waiting to testify for deposition or trial, giving testimony, preparation and/or research, whether or not services are ultimately needed (such as if last-minute settlement is reached). This fee applies even if the result of your therapist’s participation is not what you had hoped for, does not serve your interests, is contrary to your interests, or is even detrimental to your interests. Your signature below confirms that you will pay for the costs for participation in legal proceedings even if you are not the party requesting the services and that party refuses to pay. 

Payments 

All payments are due at the time of service. We accept cash, checks and Visa, Mastercard, Discover and American Express. For convenience and security, our system captures and stores credit cards electronically with your confidential profile. Please note that a $40.00 fee will be assessed for any returned or unpaid checks. 

Any client with any balance at all, for even one session, will be terminated. As stated above, if your case is closed, it may not be re-opened at any future time. 

If unusual circumstances make it impossible for you to meet your financial obligations, please notify us in writing as soon as possible to avoid any misunderstandings and keep your account in good standing. In rare cases, on a case-by-case basis, delay in payment may be permitted if a payment plan is arranged in writing with the approval of your therapist or the NW EMDR administrator. 

Insurance 

We will perform a courtesy benefits check but we encourage you to contact your insurance provider directly to see if your therapist is in-network. It is your responsibility to understand the limitations, requirements, and/or exclusions of your mental health insurance benefits. Not all services are covered and clients may have a deductible to reach. Not all diagnoses are covered by every insurance plan. You are responsible for the balance left after your insurance pays or for any charges that your insurance does not cover including co-payments and no-show fees. If your insurance demands a “claw back,” where they demand the return of money already paid out, it will be your responsibility to cover those costs, not the responsibility of NW EMDR. 

Cancellations/missed sessions 

Northwest EMDR Therapy’s missed appointments and/or cancellations policy is as follows: 

• If you are unable to keep an appointment, please notify Northwest EMDR Therapy immediately via phone or email. Appointment times, therapist availability and offices are reserved specifically for you, and we require a minimum of 24 business hours’ notice to change or cancel. If the appointment is cancelled or missed without 24 business hours’ notice, you will be charged at Northwest EMDR Therapy’s current full session rate.

• Clients are responsible for cancelling and/or rescheduling their appointments.

• Clients must provide a minimum of 24 business hours’ advance notice to cancel or reschedule an appointment.

• Cancellation calls or emails are taken between 9 am and 5 pm Monday through Friday, excluding New Year’s Day, Independence Day, Thanksgiving Day, and Christmas Day.

• Monday appointments must be cancelled before 5 pm on the previous Friday.

Crisis/urgent needs

Northwest EMDR Therapy is designed to be an outpatient program; therefore, we are unable to respond in a guaranteed timely manner to a mental health emergency or crisis. If you or someone you know needs urgent help, please call 911 or go to your closest emergency department. If you feel the issue is important, but can wait until our regular operating hours, please feel free to leave us a voicemail stating your urgent need and we will respond to it as soon as possible within our regular business hours. 

Community resources you may also contact:

Washington state 

• Clark County Crisis Line: 360-696-9560

• Cowlitz County Crisis Line: 360-425-6064

• Skamania County Crisis Line: 509-427-3850

Oregon state

• Clackamas County Crisis Line: 503-655-8585

• Multnomah County Crisis Line: 503-988-4888

• Washington County Crisis Line: 503-291-9111

National Suicide Prevention Lifeline/Veteran’s Crisis Line, a free, 24-hour hotline: 1- 800-273-8255 

Dual Roles

We do not engage in dual roles that could compromise or undermine your therapy. For that reason, therapists do not engage in social, personal, financial, or romantic relationships with clients, former clients, or people close to them outside of the therapy office.

Social Media

Therapists at NW EMDR do not engage in social media with clients on any platform such as but not limited to Facebook, Instagram, LinkedIn, TikTok. We do not “friend” clients or accept “friend” requests. If a request is accepted or sent in error, it will be retracted once realized.

Public encounters

To protect your privacy as well as the integrity of the therapeutic relationship, our policy is that NW EMDR therapists do not greet, acknowledge, or engage in public encounters with clients or former clients outside the office.

I/we have been offered: 

• A copy of the individual therapist’s Disclosure Statement (online) • Consent and Disclosure (this form) • Notice of Privacy Practices (HIPAA) 

Acknowledgment I/we have read and understand the information provided above, and hereby give Northwest EMDR Therapy consent for treatment. I have been provided a copy of the Disclosure. If I provide my signature for services to a child, I hereby certify that I have the authority to provide sole consent for that purpose. I/we have read and understand the fee and payment agreement. I/we understand that failure to pay and failure to attend services may result in termination of services. Signature(s) on this Disclosure means I have reviewed, understand, and consent to the points above and indicates my consent to treatment at Northwest EMDR Therapy, PLLC. If my signature is made via electronic means, I acknowledge that an electronic signature carries the same intention and power to bind as if hand written.