PROFESSIONAL DISCLOSURE STATEMENT

AB Creative Counseling, PLLC

Annette Berlin LMHCA 60755970

206-259-0146

9am-2pm 4-6pm Tuesday-Friday / 10am-4pm Saturday

WAC246-809-710 requires the disclosure of the following information in written form by counselors to their clients.

Please take the time to carefully read 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 treatment.

I am a licensed independent MHCA 60755970 in Washington State and I received my Master’s Degree in Psychology from Sonoma State University.

Welcome to AB Creative Counseling, PLLC

Thank you for taking the time to read the information. I want you to feel comfortable about the counseling process and working with me. Let me know when you have any concerns or questions about anything

you read below.

ABOUT ME AND MY APPROACH

My name is Annette Berlin, and I am a licensed Mental Health Counselor-Associate, which means I’m obtaining post-graduate hours toward licensing and will be supervised until I am fully licensed. I have worked in the mental health social services and art therapy field for 8 years and I have a Masters degree in Psychology with an emphasis in Art Therapy. Art Therapy is a recognized therapeutic practice in the Mental Health field that has been applied for self-esteem, social development, process trauma, and connecting to emotions, imagination, and creativity. I have been professionally trained as an art therapist.

Additionally, I utilize a variety of evidence-based practices (attachment, somatic,

mindfulness, humanistic, archetypal, and family systems). I believe, it is within a therapeutic space and a healthy relationship between counselor and client that one gains insight and ability to tap into their deepest capacities for healing and personal development. My role is to guide you in your healing journey by counseling in a way where you will feel safe, encouraged, and understood.

APPOINTMENTS AND FEES

You have the right to refuse or terminate counseling at any time. I also have the right to terminate counseling if necessary, and I will discuss with you referral options and possible next steps to ensure that your needs are met. You have the right to choose whichever provider and treatment modality best suits your needs. Individual appointments are $130. Couples, and family appointments are $150 and last 54 minutes unless other arrangements are made with AB Creative Counseling. All document preparation related to court as well as transportation, coordination, and attending court is billed at $130 per hour. I try my best to minimize rate changes, but I may increase my rate in the future. If I decide to increase my rate, you will be notified 30 days before the rate increase. For those with alternative financial arrangements, the payment agreement may be discussed periodically to evaluate the agreement. If necessary, a 30-day notification will be provided in the event of a rate increase.

CANCELATIONS

My practice’s hours are by appointment only. A 48-hours notice is required if you will be unable to make your appointment, otherwise, you will be responsible for payment of $100 for the missed session. Please note, that insurance does not cover missed appointments, so you will be responsible for paying for the entire cost of the missed appointment.

EMERGENCIES

If you have a medical emergency, please contact 911. If you have a mental health emergency please call (360) 452-4500 to reach the Crisis Clinic in your area or go to your nearest emergency room. AB Creative Counseling does not provide crisis management services.

CONFIDENTIALITY

Counseling is a personal process and all of our sessions will be confidential. In other words, I will not share anything we talk about with anyone else. However, there are a few exceptions when I will need to break confidentiality: 1) If you are a threat to harm yourself or someone else, 2) If you report suspected abuse or neglect of a child or a vulnerable adult, 3) If I receive a subpoena from the courts to share information, 4) If you permit me to share your information with another person, 5) If you bring legal charges against me, and 6) If you are in couples therapy with me and individual therapy, I will not keep affairs or other acts of infidelity confidential from your partner(s).

I cannot guarantee confidentiality through email. Please refrain from including personal

health information (PHI) in this mode of communication. If you prefer to email, I will do my best to respond in a timely fashion. It is my preference that you call or text me, but you can also utilize the client portal’s secure messaging system. My phone service and client portal messages are both HIPAA compliant and confidential.

INSURANCE AND THE USE OF DIAGNOSIS

I am an in-network provider with Aetna, Kaiser, and Premera.

insurance companies. I am considered an out-of-network provider with other insurance

companies. If you have insurance in which I am in a network, I will bill insurance for you, where you will be responsible for meeting your deductible and paying any co-payments or co-insurance you have. For all other insurances, you are responsible for filing for reimbursement with your insurance and finding out whether they will reimburse you for the services I offer. There is a wide range of reimbursements depending on the insurance company and level of plan, so please be thorough in your research before beginning counseling with me. I can assist you in the process of filing for your insurance by providing appropriate documentation. Insurance companies usually require a mental health diagnosis. And, some diagnoses qualify for reimbursement, while others may not depending on the insurance company. All mental health diagnoses become part of your permanent insurance record, which I believe is important to consider before filing for insurance. Also, insurance companies may request for your entire medical record, which may include therapeutic notes that I keep confidentially about your treatment.

TELEMEDICINE

I agree to engage in telemedicine at AB Creative Counseling, PLLC as part of my counseling. I understand that “telemedicine” includes the practice of health care delivery, assessment, diagnosis, consultation, treatment, transfer of medical data, and psychoeducation using interactive audio, video, or data communications.

Technology: I understand that I will need to login to Zoom to use this platform. I also

need to have a broadband Internet connection or a smartphone device with a good cellular connection at home or at the location deemed appropriate for services. I also understand that in case of technology failure, I may contact my counselor directly at AB Creative Counseling, PLLC via phone to coordinate alternative methods of treatment. Financial obligations: Fees associated with telemedicine appointments are payable by credit or debit card only and are the same as in-person visits.

My rights for telemedicine: I understand that I have the following rights concerning

telemedicine: 1. I have the right to withdraw my consent at any time. 2. I understand that there are risks and consequences associated with telemedicine including, but not limited to the possibility, despite reasonable efforts on the part of my counselor/therapist/clinical intern, that the transmission of my medical information could be disrupted or distorted by technical failures. Also, I understand that telemedicine-based services and care may not be as complete as face-to-face services. 3. I understand that I may benefit from telemedicine but that results cannot be guaranteed or assured.

COMPLAINT

If you have any concerns or complaints about me or the services you receive, please let me know. I would love the opportunity to address your concerns. If you want to file a formal complaint, you may send a complaint to the Department of Health,

Health Professional Quality Assurance Division, P.O. Box 47869, Olympia, WA 98504-7869. Their telephone number is (360) 236-4700.

Thank you. I look forward to working with you,

Annette Berlin

By signing below, you confirm that you have read, understood and agreed to the information on this professional disclosure statement.

Signature of

financially responsible party____________________________________________________

Relationship to patient_________________________________________________________

_______________________________________________________ Date_________________

Annette Berlin / [email protected] / 206-259-0146