Professional Disclosure

Ashlee Guckel, LMHC

Mindful Moments Counseling, PLLC

I have partnered with Mindful Therapy Group for administrative services. If you have questions on scheduling, billing or technology issues please contact: admin@mindfulsupportservices.com

425-640-7009

7am-7pm Mon-Friday

8am-4pm Saturday-Sunday

WAC246-80710 requires the disclosure of the following information in written form by counselors to their clients.

Please take the time to carefully read and sign this disclosure statement. As my client, you have the right to know my qualifications, methods, and mutual expectations of our professional relationship. The information presented here is provided to help you decide if my services are suitable for your needs. Please discuss any questions or concerns you may have either now or during the course of your therapy.

My Qualifications and License

I am a Licensed Independent Mental Health Counselor in Washington State LH 60729180. I received my Master’s of Science in Mental Health Counseling from Central Washington University in 2010.

My professional background involves working in inpatient settings with adults, outpatient settings with adults, and crisis response and outreach to local hospitals. My experience as a mental health counselor equipped me to work with clients who struggle with a wide range of issues including depression and mood related disorders, anxiety, adjustment disorders, personality disorders, and other diagnoses including psychosis. I have also acquired a specialty working with individuals with developmental and intellectual disabilities and am an approved clinical supervisor.

The Therapeutic Process

I believe that therapy is fundamentally about growth, finding your unique self while learning to embrace the challenges of life. Everyone has a unique story and it is my passion to hear yours as we develop an authentic therapeutic relationship and navigate through struggles as you work towards achieving your goals for therapy. My therapeutic modality is a blend of person centered, mindfulness and neuroscience, cognitive behavioral therapy, solution focused, and dialectical behavioral therapy as needed.

Therapy has both benefits and risks. During the course of therapy, you might notice changes in your symptoms, problems, and functioning. Since we will be exploring challenging territory in your life, you might experience greater difficulty throughout the work at first. Therapy typically produces benefits over time, but sometimes as you get to the root of sensitive unresolved issues, you may feel temporarily more acutely than in the past. I cannot offer any promise or guarantee about the resolutions, but we will build on your strengths and as you commit yourself to work through your vulnerable issues and build upon your strengths, it is likely that you will see improvements throughout our work and in the future.

I work with all my clients on a reoccurring, weekly basis. If you cancel several sessions, I may take you off the reoccurring schedule and you will be placed on an on-call list. You will then be able to schedule sessions as needed and fill in other cancellation slots. I will reach out to you by phone as those times become available. If you do not show up to your appointment without notifying me, all your future appointments will be canceled until I hear from you.

Client Rights and Responsibilities

Clients have the right to choose a therapist who best suits their needs and purposes. You may ask questions about treatment at any time and may choose to terminate therapy at any time. Therapy may also be ended when I feel that your needs will be better met by another provider. In that case, I will try my best to make appropriate referrals. If you have any concerns or complaints, you may contact:

Department of Health, Health Systems Quality Assurance Complaint Intake 360-236-4700, HSQAComplaintIntake@doh.wa.gov, P.O Box 47857, Olympia, WA 98504-7857.

Services

I offer therapy services for individuals, couples, and families. I see clients ages eighteen and up. I do not offer case management services, which include but are not limited to providing paperwork for disability, unemployment, custody, adoption, foster care, car accidents, and any type of legal issues. I do not offer therapy for individuals who are court mandated for treatment or seeking treatment in which disclosure of sessions will need to be provided to an outside entity.

Virtual Sessions

I hereby consent to engage in Telehealth. I understand that “telehealth” includes the practice of health care delivery, diagnosis, and treatment consultation using interactive video, audio, and/or data communications. For Telehealth sessions, we will be connecting using a system that is encrypted to the federal standard and HIPAA compatible. It is my responsibility to choose a secure location to interact with technology-assisted media and to be aware that family, friends, employers, co-workers, strangers, and hackers could either overhear our communications or have access to the technology that you are interacting with. Additionally, I agree not to record any Telehealth sessions. During a Telehealth session, we could encounter a technological failure. The most reliable backup plan is to contact one another via telephone. I will ensure that I have a phone with me, and I have provided that phone number to you. I understand that all fees for Telehealth and non-Telehealth services are the same. I am financially responsible for all services rendered, late cancellations, and missed appointments.

Emergencies

As an independent, private practice clinician, I do not offer crisis coverage. If you are experiencing emergencies or a threat to yourself and/or others, please call 911 or go to the nearest hospital emergency department. You may call 1-866-4CRISIS (1-866-437-4747) for urgent mental health crises.

Financial Responsibilities

Please confirm your insurance coverage and patient responsibility before your first appointment with me. Your co-pay or patient responsibility (deductible) determined by your insurer is due at each visit before your session begins. My private pay rate is $150 per 53-minute session for individuals and $170 per 53-minute session for couples/families. If you are unable to pay the associated fees at the time of service for more than one visit, without developing a payment plan, your future appointments will be suspended until unpaid balances are resolved. Additional fees may apply for preparation of requested documents or copying and sending records. I will discuss any fees with you at the time of a request.

Your appointment time is reserved specifically for you, and I will ask all my clients to respect this time. A minimum of 48 hours’ notice is required to reschedule or cancel without a fee. You will be responsible for the session rate (either $150 or $170) for cancellations and no shows with shorter notice than 48 hours. Insurance cannot be billed for missed sessions. Since this fee is assessed at my discretion, please direct all questions to me, not the administrative staff.

I authorize my provider, Ashlee Guckel LMHC, and Mindful Therapy Group to release information to insurance carrier(s) listed and be paid directly by insurance carrier(s) for services billed. I acknowledge that I am responsible for all charges not paid by my insurance companies including copays, coinsurance, deductibles, insurance plan refusal to pay for failure to obtain authorization, and missed and late cancellation fees. If it becomes necessary to effect collections of any amount owed, the undersigned agrees to pay all costs and expenses, including reasonable attorney fees.

If an unpaid patient balance of $100 or over remains after 120 days, your balance will be turned over to a third-party collection agency. You will receive a final courtesy phone call and/or letter to remind you of your balance due. If you believe that there is an error in your billing, please let us know as soon as possible so we can research the issue. Unpaid balances without a payment plan or partial payment initiated after 120 days will initiate a phone collections effort for recovery, and some identifying confidential information will be released in this process. This may negatively impact your credit. It is very important that you update your contact information with us to ensure you are aware of your financial responsibility and receive your statements.

Confidentiality and Access to Records

All information disclosed within sessions is confidential. It will not be disclosed to anyone without your written permission. Disclosure will be required when a client is a danger to self or others.

I keep brief notes of your sessions and you have the right to a copy of your medical records at any time. A response to your request will be made within 15 working days; this is compliant with RCW 70.02.080

My signature below is acknowledgement that I am the client, or the person authorized to consent for mental health treatment for the client and consent to services provided by Ashlee Guckel LMHC, that I have read and understood the disclosure information and have received a copy of this disclosure form.