+Mindful Therapy Group

Collaboratively Striving to Meet the Mental Health Needs of Our Community

21907 64th Ave W Suite 220

MountlakeTerrace, WA 98043
Phone: 206.319.4446
Fax: 425.640.9600
E-Mail: info@mindfultherapygroup.com
Web: www.mindfultherapygroup.com

Agreement Regarding Services, Fees, and Client’s Rights and Responsibilities

Purpose of this agreement:

This agreement provides you the client with an outline of what you can expect from your therapist and what we
will expect of you as we work together. In order to provide the highest quality of care, we want to give you as much
information as you need to answer all of your questions.

Our Mission:
“Collaboratively Striving to Meet the Mental Health Needs of Our Community”

We are a group of skilled Mental Health Professionals collaborating in an innovative way reaching multiple mental health
diagnoses and issues. Each clinician specializes in something different and unique including but not limited to acute and
complex mental illness, adolescents, eating disorders, trauma, sexual abuse and domestic violence, chemical
dependency and dual diagnosis, child life and developmental therapy, parenting assessments and coaching.

Professional Standards and Ethics:

All of the therapists in Mindful Therapy Group are licensed by the State of Washington Department of Health
(DOH) and have fulfilled all of the requirements required to provide your mental health services. You may search our
individual credentials on the DOH website at www.doh.wa.gov, or call (800) 525-0127.

Appointments:
All appointments are scheduled for 50 minutes each. If you are late to your appointment the lost time will be part
of your scheduled time. If you are unable to keep an appointment, please give at least 24 hours advance notice.
Otherwise, you will be charged the full fee for the time that we have reserved for you. We will provide you with adequate
notice if either one of us will be unavailable for a scheduled appointment and be more than happy to reschedule as
needed.
NOTE: we will provide an initial phone consult of 15 minutes free of charge to determine compatibility at the
patient’s request.

Fees:
The standard fee is $100-120 per session. There is a limited number of sliding scale session blocks available for
those clients who qualify. The fee for service in these cases is based on a sliding scale that is determined by the client’s
income and number of dependents. Payment in full is due at the time of each session if insurance will not be billed. If an
unpaid balance remains after 30 days, a finance charge of 5% will be added to the balance each month until the bill is
current. Unpaid balances that exceed 90 days may be sent to collections for recovery and some identifying confidential
information will be released in this process.
We reserve the right to bill our standard fee for case coordination, clinical and legal write- ups, and phone
consultations exceeding 5 minutes per week. Our time is valuable and is best served providing high quality mindful
therapy to you while you are here in session. There is no charge for routine telephone calls to our administrative assistant
regarding scheduling, appointments, or billing.
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Insurance:
We are currently accepting all forms of insurance, and can bill out-of-network for those plans where we are a
participating provider. We will make every effort to match you with Providers who are contracted with your insurance, but
may ask that you see an out-of-network provider in special needs situations and on a case by case basis. Please provide
full insurance information and your insurance card upon your initial visit to determine eligibility of benefits. Copay/
Coinsurance will be billed.

Confidentiality:
Information discussed during the course of therapy is confidential. By law, information concerning treatment may
be released only with the written consent of the person treated (or the person's guardian if applicable). In the event where
there is suspected child or elder abuse or an imminent danger of harm to one's self or others, the law requires the release
of confidential information. In these instances we are required to make a report to the appropriate authorities. In addition,
the courts may subpoena treatment records in certain circumstances. Any type of release of confidential information will
be discussed with you.
I am compliant with the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides
privacy protections and new patient rights with regard to personal health care information. HIPAA requires that I provide
you with a Notice of Privacy Practices. This Notice, which is attached to this agreement, explains HIPAA in detail and its
application to your personal health care information.

Notice of Privacy Practices

The privacy of your health information is important to me. I will maintain the privacy of this information and not
disclose it to others unless you request this of me, or the law requires me to do so. This notice describes how I may use
and disclose your protected health information (PHI) to carry out treatment, payment or health care operations. This notice
also describes your rights regarding health information I maintain about you and how you may exercise these rights. I am
required, not only to abide by, but also to notify you of these practices. Please review this notice carefully. If you have
questions regarding any of the following information, I would be happy to discuss these with you.

How I may use and disclose your PHI

A. Permissible Uses and Disclosures without Your Written Authorization

I am bound by professional ethics to protect client rights to confidential communications regarding their care. I
may use and disclose PHI without your written authorization for the purposes below. In any case that PHI is disclosed, I
maintain a minimum necessary policy. That is, I disclose only the information necessary for any of the following purposes,
no more.
1. Treatment: I may use and disclose PHI in order to provide, coordinate and/or manage your treatment. This may
include consultation with other professionals or clinical supervisors to the extent they need to know the information.
2. Payment: I may use and disclose PHI so that services you receive are appropriately billed to, and payment is
collected from, your health insurance provider. examples of disclosures pertaining to payment include: making a
determination of eligibility for insurance coverage or authorizing treatment; processing claims; conducting utilization
reviews and/or collections activities.
3. Health Care Operations: I may use and disclose PHI for quality improvement practices, certification, licensing
or credentialing activities. These may include disclosure to contracted parties for billing or administrative services.
4. Required or Permitted by Law: I may use or disclose PHI when I am required or permitted to do so by law.
Examples of possible disclosures of this type include: belief that you or someone else is a possible victim of abuse,
neglect, domestic violence or other crimes, or is in imminent risk of harm; response to a court order or other lawful
process by judicial and law enforcement officials; for national security; family involvement in care; research; client medical
emergency, disability or death; audit or investigation by government agencies; or as otherwise authorized by law.

B. Uses and Disclosures Requiring Your Written Authorization

The following conditions require that I obtain a signed “Release of Information” form from you in order to disclose
PHI. Know that you may revoke this release at anytime.
1. Psychotherapy Notes: These are notes recorded by me documenting the contents of a therapy session and will
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be used only by me, for the purpose of treatment.
2. Other Uses and Disclosures: These are situations not included in section 1. A. above, and may include:
sending PHI to a school or attorney.

Your Rights regarding your PHI

A. Right to Inspect and Copy: You have the right to inspect and copy your PHI. This right is restricted only when
there is compelling evidence that access to this information would cause serious harm to you. There may be
administrative fees associated with making copies of your record.
B. Right to Alternative Communications: You have the right to request any reasonable alternative means or
location of communication.
C. Right to Request Restrictions: You have the right to request a restriction on PHI use and/or disclosure for
treatment, payment or health care operations. I am not required to agree to any particular restrictions you may request.
D. Right to Accounting of Disclosures: You have the right to request an accounting of certain PHI disclosures, for
purposes other than treatment, payment or health care operations.
E. Right to Request and Amendment: You have the right to request that I amend your health care information. I
am not required to accommodate your request.
F. Questions and Complaints: If you have any questions pertaining to this notice, please contact me with the
contact information above. If you believe your privacy rights have been violated, you have the right to file a complaint with
the Secretary of Health and Human Services at 200 Independence Ave SW, Washington, DC 20201, (202) 619-0257, or
www.hhs.gov/ocr/hipaa/
G. Right to Obtain Notice: You have a right to obtain a copy of this notice.

Changes to This Notice

I may change the terms of this notice at any time. In that situation, the new notice terms will pertain to all PHI that I
maintain, including any created or received prior to issuing the new notice. If this notice changes, I will notify and provide
you with that information.
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AGREEMENT

I hereby authorize Mindful Therapy Group to render mental health services to me. I have read and
understand this agreement and have received a copy for myself.

Signed: _________________________________

Printed Name:____________________________

Date: ________________________

HIPAA
I acknowledge that I have received the Notice of Privacy Practices explaining HIPAA.

Signed: _________________________________

Printed Name:____________________________

Date: ________________________
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Mindful Therapy Group
th
21907 64 Ave. W Suite 220
Mountlake Terrace, WA 98043
206.319.4446 phone
425.640.9600 fax
Provider:________________________________

FACE SHEET

Today's Date:_____________
Client Name:____________________________________________SS#:_________________________________
Address:_________________________________________________________Apt#:_______________________
City:_____________________________________________State:___________Zip:________________________
Client's Date of Birth:_____________________ Age:________ Gender: Male ❏ Female ❏
Responsible Party:_________________________________________ Relationship:_________________________
Address if Different from client:__________________________________________________________________
Home Phone: (_____)____________________________Cell Phone: (____)_______________________________
Work Phone: (_____)______________________________Ext:________ Ok to call work? yes ❏ no ❏
Email Address:_______________________________________________________________________________
Marital Status: Single ❏ Married ❏ Partner❏ Child ❏ Other_______________❏
Preferred Method of Communication: ☐ phone ☐ email ☐ OK to leave a message

Primary Insurance Co. Name:_________________________________________________________________

Insurance Co. (800) Number:_______________________________
Name of Insured (Subscriber):_________________________________________Date of Birth:______________
Insurance ID #:_______________________________________Group#:_________________________________
Subscriber's Employer:______________________________________ SS#:_______________________________
Relationship to Subscriber: Self ❏ Spouse ❏ Child ❏ Other_______________________❏

Secondary Insurance Co. Name:_________________________________________________________________

Insurance Co. (800) Number:_______________________________
Name of Insured (Subscriber):_________________________________________Date of Birth:______________
Insurance ID #:_______________________________________Group#:_________________________________
Subscriber's Employer:______________________________________SS#:_______________________________
Relationship to Subscriber: Self ❏ Spouse ❏ Child ❏ Other_______________________❏

I authorize provider 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, deductibles, missed and late cancellation appointments.

If it becomes necessary to effect collections of any amount owned, the undersigned agrees to pay all costs and expenses,
including reasonable attorney fees.

Signature:________________________________________________________Date:_______________________
Office Use Only:

Copay:__________ or Coinsurance %__________Deductible:_________ Deductible satisfied?:___________