Welcome to my practice. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.  HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or, if you have not satisfied any financial obligations you have incurred.



I am a licensed psychologist.  I received my Ph.D. from the University of Washington in Educational Psychology.  I have several years experience as a school psychologist in the Edmonds School District.  I completed my postdoctoral training at Children’s Hospital and Regional Medical Center in Seattle, Mary Bridge Children’s Hospital in Tacoma, and the University of Washington’s Center for Human Development and Disability.

My services will consist of performing an evaluation of you/your child, and reporting the results to you.  If you request, I can also consult with you about your child’s educational needs, based on evaluation results. 

My approach to evaluation is geared specifically to your needs.  Based upon your referral question, I will utilize one or more of the following evaluation techniques: interview, observation, developmental inventory, behavior inventory, review of records, and administration of intelligence, academic, sensory, personality, and memory tests.  I will then interpret the results and share the results with you verbally and in a written report.



The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by state law and/or HIPAA.  Clients who are 13 years of age or older must sign the written Authorization form.  With your (or your 13 year-old’s or older child’s) signature on a proper Authorization form, I may disclose information in the following situations:

  • I may occasionally find it helpful to consult other health and mental health professionals about a case. If I consult with a professional who is not involved in your treatment, I make every effort to avoid revealing your identity. These professionals are legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). 
  • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
  • If you are involved in a court proceeding and a request is made for information concerning the professional services I provided you, such information is protected by the psychologist-patient privilege law. I cannot provide any information without 1) your written authorization; 2) you informing me that you are seeking a protective order against my compliance with a subpoena that has been properly served on me and of which you have been notified in a timely manner; or 3) a court order requiring the disclosure.  If you are involved in or contemplating litigation, you should consult with your attorney about likely required court disclosures.


There are some situations where I am permitted or required to disclose information without either your consent or Authorization:

  • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.
  • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.


There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice.

  • If I have reasonable cause to believe that a child has suffered abuse or neglect, the law requires that I file a report with the appropriate government agency, usually the Department of Social and Health Services. Once such a report is filed, I may be required to provide additional information.
  • If I have reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, the law requires that I file a report with the appropriate government agency, usually the Department of Social and Health Services.  Once such a report is filed, I may be required to provide additional information.
  • If I reasonably believe that there is an imminent danger to the health or safety of the patient or any other individual, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, seeking hospitalization for the patient, or contacting family members or others who can help provide protection.


If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.



The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in the unusual circumstance that I conclude that disclosure could reasonably be expected to cause danger to the life or safety of you or another or that disclosure could reasonably be expected to lead to your identification of the person who provided information to me in confidence under circumstances where confidentiality is appropriate, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most situations, I am allowed to charge a copying fee of 65 cents per page for the first 30 pages and 50 cents per page after that, and a $15 clerical fee. I may withhold your Record until the fees are paid. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.



HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you.

You have the right to refuse going through with this evaluation.  You have the right and responsibility for choosing the professional who best meets your needs.  You or your child may discontinue this evaluation at any time for any reason.  If you feel uncomfortable with my approach, it is entirely appropriate to ask for a referral to another professional.



If your child is 13 years or older and is not developmentally disabled, I will carry out the evaluation only if your child agrees to the evaluation and only if your child agrees to share the results with you. 



Payment is due at the time of service.  For one-time appointments, such as Private School Entrance Testing, or Early Entrance to Kindergarten Testing, payment will be due on the day of testing.  For comprehensive psychological evaluations, payment will be due on the date of the feedback session. 

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.  [If such legal action is necessary, its costs will be included in the claim.]



If you have a health insurance policy, it might provide some coverage for a psychological evaluation of a learning or mental disorder. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers.

You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf.

You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier.



Because I am a licensed psychologist, anyone who is dissatisfied with my services can make a complaint to the following agency:


                Health Professions Quality Assurance Division

                Licensing Board of Psychology

                PO Box 1099

                Olympia, WA 98507-1099