Client Intake Form

1. The “Person(s) Responsible for Payment” is personally responsible for the payment of my professional fees. This includes payment for appointments which are made but not kept or rescheduled by you, or, if a health insurance carrier or EAP does not reimburse claims due to ineligibility for coverage. [NOTE: This office does not mail out bills for missed appointments. Please complete the attached Personal Guarantee of Payment.]
2. This office only submits claims to one (“primary”) insurance plan. Payment of benefits is assigned to my office. If an insurance claim is denied by the insurance carrier, the Person(s) Responsible for Payment is ultimately responsible for payment of fees. Amounts due for over 60 days are subject to collection by third party agencies if necessary.
3. Insurance claims require a diagnosis to be submitted to the carrier. It must be a diagnosis for which your policy has determined treatment to be medically necessary. (Your carrier should define this term in your benefit plan’s description.u0000) Re-authorization for more treatment sessions requires that I disclose information about you to your insurance company. You may view this information in advance.
4. Accepting a new appointment, indicating date and time, is an agreement. Rescheduling by you must be done over the phone with me within no less than 48 business hours of the original appointment. This policy is further described in the attached Disclosure Statement.

Subject to my review of the attached Disclosure Statement, I freely consent to receive, or discontinue with proper notice, diagnostic and treatment services from Robert Odell, LICSW. I have been given information regarding my rights and responsibilities as a client. I may address any concerns or grievances with Robert Odell, or the Washington Department of Health.

My signature below confirms my understanding and agreement to the terms above, and to receive services from Robert Odell, LICSW.u0000u0000

Credit/debit card or bank checking account information (including pre-tax medical flex accounts) is used for the personal guarantee of payment. Account number is transferred to a digitally encrypted format. The only circumstances under which the account will be accessed are:

1. Payment for services: For services rendered on a private (not insured) basis, the amount due will be deducted from
2. Insurance-related payment: For payment of a deductible, co-insurance or co-payment. If insurance is denied due to lack of member eligibility, payment of fees specified in Section II A. of the Disclosure Statement below.
3. No show/late cancellation/reschedule: In the event that a client makes an appointment but does not keep it, or fail to provide notice within 48 hours, cancellation policies apply (see Disclosure Statement.) No separate statement or bill will be issued by US Mail. The amount due is deducted within one week of the appointment date.
4. Account change: If your account information changes, or charges declined, you agree to provide new, valid account information upon request.

   You are entitled to receive a written receipt for any payments you have made.u0000u0000u0000

Robert Odell, LICSW
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I am required by law to maintain the privacy of your health information. I am also required to give you this Notice about my privacy practices, legal obligations, and your rights concerning your health information ("Protected Health Information" or "PHI"). I will follow the privacy practices that are described in this Notice. If I amend this Notice, I will provide you with the amended Notice for your information and signature.

For more information about my privacy practices, or for additional copies of this Notice, please let me know your questions as soon as they arise.

I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

1. Permissible Uses and Disclosures Without My Written Authorization. I may use and disclose your PHI without your written authorization for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures of your mental health information that are legally permissible.
   1. Treatment: I may use and disclose your PHI to other clinicians involved in your care in order to better provide integrated treatment to you. For example, I may discuss your diagnosis and treatment plan with your psychiatrist or nurse practitioner. In addition, I may disclose your PHI to other health care providers in order to provide you with appropriate care and continued treatment.
   2. Payment: I may use or disclose your PHI for the purposes of determining coverage, billing, claims management, and reimbursement. For example, a bill sent to your health insurer may include some information about our work together so that the insurer will pay for the treatment. I may also inform your health plan about a treatment you are going to receive in order to determine whether the plan will cover the treatment.
   3. Health Care Operations: I may use and disclose your PHI in connection with health care operations, including quality improvement activities, training programs, accreditation, certification, licensing or credentialing activities. For, example, I may disclose disguised information about our work for training purposes.
   4. Required or Permitted by Law: I may use or disclose your PHI when I am required or permitted to do so by law. For example, I may disclose your PHI to appropriate authorities if I reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or the possible victim of other crimes. In addition I may disclose your PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Other disclosures permitted or required by law include the following: disclosures for public health activities; health oversight activities including disclosures to state or federal agencies authorized to access your PHI; disclosures to judicial and law enforcement officials in response to a court order or other lawful process; disclosures for research when approved by an institutional review board; disclosures for workers’ compensation claims, and disclosures to military or national security agencies, coroners, medical examiners, and correctional institutions as authorized by law.
2. Permissible Uses and Disclosures That May Be Made Without My Authorization, But For Which You Have An Opportunity to Object.
   1. Fundraising: I may use your PHI to contact you in an effort to offer you new services. I may also disclose PHI to any foundation with which I am connected so that the foundation may contact you in an effort to raise money for its operations. Any fundraising communications with you will include a description of how you may opt out of receiving any further fundraising communications.
   2. Family and Other Persons Involved in Your Care. I may use or disclose your PHI to notify, or assist in the notification of (including identifying or locating) your personal representative, or another person responsible for your care, location, general condition, or death. If you are present, then I will provide you with an opportunity to object prior to such uses or disclosures. In the event of your incapacity or emergency circumstances, I will disclose your PHI consistent with your prior expressed preference, and in your best interest as determined by my professional judgment. I will also use my professional judgment and my experience to make reasonable inferences of your best interest in allowing another person access to your PHI regarding your treatment with me.
   3. Disaster Relief Efforts. I may use or disclose your PHI to a public or private entity authorized by law or its charter to assist in disaster relief efforts for the purpose of coordinating notification of family members of your location, general condition, or death.
3. Uses and Disclosures Requiring Your Written Authorization.
   1. Psychotherapy Notes. I will not disclose the records of our work that I keep separate from the medical record for my personal use, known as psychotherapy notes, except as permitted by law.
   2. Marketing Communications; Sale of PHI. I must obtain your written authorization prior to using or disclosing your PHI for marketing or the sale of your PHI, consistent with the related definitions and exceptions set forth in HIPAA.
   3. Other Uses and Disclosures. Uses and disclosures other than those described in this Notice will only be made with your written authorization. For example, you will need to sign an authorization form before I can send your PHI to your life insurance company or to your attorney. You may revoke any such authorization at any time by providing me with written notification of such revocation.

II. MY INDIVIDUAL RIGHTS

1. Right to Inspect and Copy. You may request access to your medical records and billing records maintained by me in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, I may deny access to your records. I may charge a fee for the costs of copying and sending you any records requested.
2. Right to Alternative Communications. You may request, and I will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
3. Right to Request Restrictions. You have the right to request a restriction on your PHI that I use or disclose for treatment, payment or health care operations. You must request any such restriction in writing addressed to Robert Odell, MSW, LICSW, 3213 W. Wheeler St., Seatle WA 98199. I am not required to agree to any such restriction you may request, except if your request is to restrict disclosing your PHI to a health plan for the purpose of carrying out payment or health care operations, the disclosure is not otherwise required by law, and the PHI pertains solely to a health care item or service which has been paid in full by you or another person or entity on your behalf.
4. Right to Accounting of Disclosures. Upon written request, you may obtain an accounting of disclosures of your PHI made by me in the last six years, subject to certain restrictions and limitations.
5. Right to Request Amendment. You have the right to request that I amend your PHI. Your request must be in writing, and should explain why the information should be amended. I may deny your request under certain circumstances.
6. Right to Obtain Notice. You have the right to obtain a paper copy of this Notice by submitting a request to Robert Odell, MSW, LICSW at any time.
7. Right to Receive Notification of a Breach. I am required to notify you if I discover a breach of your unsecured PHI, according to requirements under federal law.
8. Questions and Complaints. If you desire further information about your privacy rights, or are concerned that I have violated your privacy rights, please contact me at 206-282-3137. You may also file a written complaint with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. I will not retaliate against you if you file a complaint.

III. EFFECTIVE DATE AND CHANGES TO THIS NOTICE

1. Effective Date. This Notice is effective on 02/29/2016.
2. Changes to this Notice. I may change the terms of this Notice at any time. If I change this Notice, I may make the new notice terms effective for all PHI that I maintain, including any information created or received prior to issuing the new notice.

If I change this Notice, I will post the revised notice in the waiting area of my office and on my website at seattle-counseling.com. You may also obtain any revised notice by asking me directly.

It is your right as a client to select the mental health professional who best suits your needs. Before you sign this statement, your consent to treatment requires that you know about my services, and the terms under which I provide them.

I practice according to the Code of Ethics of the Clinical Social Work Association. A copy of this Code is available on request. Please refer to the attached summary of the ethical practices I observe.

I. DISCLOSURE TO CLIENT

1. Credentials
   I am a Licensed Independent Clinical Social Worker, and not affiliated with any other practitioner(s). At your request, I can describe the requirements for State of Washington licensure for Clinical Social Work.

2. Confidentiality
   The confidentiality of our work is of utmost importance. State of Washington law holds that our communication is privileged information, identical to that between doctors and patients, or lawyers and clients. See Section II. A(b) below.

   If your mental health insurance benefit requires a review of treatment to authorize additional sessions, then certain information about you may have to be shared with an insurance or managed care company. I will always review these disclosures with you in advance. Please review the information about my patient Privacy Practices mandated by the 1996 Federal law known as Health Insurance Portability and Accountability Act (HIPAA).

3. Education, training & experience
   I received my Masters degree from the University of Southern California School of Social Work. In this program, I completed two one-year clinical internships: a Los Angeles County community mental health clinic serving indigent, severely/persistently mentally ill and homeless populations; and, a corporate employee assistance program (EAP), providing assessment, counseling and referral for personal, work-related and chemical dependency problems.

   My post-graduate clinical experience includes individual & family therapy in a South Central Los Angeles psychiatric hospital. I then practiced in a Los Angeles court mandated residential treatment center for adolescent boys, including sex offenders, providing individual, group and family treatment.

   I have provided individual and family therapy, case management and emergency room psychiatric assessments throughout Seattle, for Fairfax Hospital. In 1998, I began an office practice in an adjacent clinic, working with psychiatrists, psychologists, nurses, clinical social workers, marriage & family therapists and mental health counselors. I have practiced independently and privately since 1999.

   My continuing education has included training in relationship therapy, human sexuality, ethics, clinical supervision, workplace trauma debriefing, abuse prevention and reporting, suicide prevention.

4. Types of psychotherapeutic counseling provided
   Relationships, with an approach that integrates sexuality; Adults, specializing in the treatment of depression, anxiety disorders (Panic, PTSD), grieving, problems related to work and career, and relationships;
5. Counseling methods
   No treatment method is more important to me than your belief that we are collaborating in finding new possibilities for your health and well-being. My methods are guided by understandings of how people develop over time. I am interested in individual growth, and how it is effected by important relationships. I try to get as close as I can to the meanings that you find within these relationships, in your personal and family histories, life events, and the successes and problems of living.
6. Course of therapy
   If you wish, we can agree in advance to the number of sessions in your treatment plan. You have the right to cancel treatment at any time, subject to the 48 hour notice requirement described below in the Statement of Office Policies, Section B. below.
7. Professional associations
   I served a two year term as President of the Board of Directors of the Washington State Society for Clinical Social Work from 2008-2010. I am a Founding member of the national Clinical Social Work Association
8. Complaints
   If you have a complaint or inquiry about my professional services, you may contact the State of Washington Department of Health. I maintain forms and instructions for such complaint or inquiry.

II. STATEMENT OF OFFICE POLICIES

1. Fees & Payment Policies. Please refer to your signed copy of my Financial Policies statement. Here is a schedule of my fees, as submitted for private payment or for insurance reimbursement:
   
   

   Session Type	Duration	Fee
   Diagnostic	55 minutes	$200.00
   Individual	50 minutes	$150.00
   	80 minutes	$180.00
   Relationship	50 minutes	$180.00
   	80 minutes	$240.00

   2. Reports: Authorized releases of treatment information to third parties is accomplished by a report separately written by me (Psychotherapy Notes are separately stored from the Medical Record, as defined by Federal law, and as such the Notes are not typically discoverable.) My charge for writing these reports is $100/hr. The number of hours will be agreed to in advance. Insurance does not reimburse this service. My fee for phone based professional consultation with other mental health or medical professionals is $100/hr
   3. Appointment policy: In relationship therapy, the relationship is the client.
   4. Treatment records: Records consist of the Medical Record, which contains basic/generic information about any appointment. Relational partners jointly hold rights to their Medical Record. Waivers must be signed by both parties in order to release it to any one party. More specific and particular content of therapy is recorded in the Psychotherapy Notes, which I maintain separately from the Medical Record. Under the law (HIPAA), Psychotherapy Notes are my property, and are broadly protected, including in legal proceedings like divorce actions, or medical disability applications.

2. Appointment cancellation, rescheduling and changes. Your appointment is an agreement to meet on that date and time. If you do not appear, your credit or debit account will be charged via the pre-authorization in the Personal Responsibility for Payment form.

   I accept voice mail and e-mail, for changing or canceling appointments. For Monday appointments, notify me no later than Thursday 12P; for Tuesday, no later than Friday 12P.] If you are late, and do not notify me by phone, I will remain in the office for a maximum of 30 minutes past the appointment time.

   For a late cancellation (less than 48 hours notice): If you reschedule within 4 business days, I charge a fee equal to 75% of what I normally receive from you and/or your insurance carrier. After four business days, the full cancellation fee will be charged. If I fail to appear, without notice, for your appointment, either your insurance co-payment, or your private fee for the next appointment will be waived. (See below,¶2 of Special Office Policies, for Emergency Service notice)

3. Insurance coverage. Most insurance policies cover treatment by Licensed Independent Clinical Social Workers. I bill your insurance company, and they will issue statements to my office and to you of benefits paid or denied. Health insurance carriers need a diagnosis for which they consider psychotherapy treatment to be "medically necessary." I must evaluate on an ongoing basis whether your symptoms meet these 'medical' criteria. If they do not, I cannot submit claims. I can help you evaluate whether this requirement fits with your therapeutic goals.
4. Urgent or emergency contact. I make reasonable efforts to be reachable by phone, text or e-mail if you urgently need to speak to me. I cannot return your call while in session with another client. I will return your call at your request. If your situation is life-threatening or psychiatrically disabling, please dial 911. If you are in a crisis before we are able to speak, call the King County United Way Crisis Line at (206) 461-3222. They can refer you to a community resource, including emergency assistance.

AGREEMENT

Prior to signing below you have the opportunity to ask Robert Odell for further explanation, or have received same, for any of above disclosure information and office policies.

PLEASE NOTE APPOINTMENT CANCELLATION POLICY - 48 BUSINESS HOUR REQUIRED NOTICE

My primary goal is to develop the closest possible treatment relationship with you in the most ethical environment I can create. Disclosure of these professional and personal ethics to you seeks to prevent relationship practices that I believe can hurt or destroy treatment. If you have questions or concerns about any of these policies, please discuss them with me as soon as possible.

1. Your rights as a client do not end when the treatment relationship ends, including the right to confidentiality. I only disclose information about you with your informed consent or written permission. Neither your death nor mine terminates these rights. Exceptions are specified under Federal laws, and the State of Washington (RCW). Written records are destroyed 5 years after the last date of service.
2. I will not develop a social relationship with you outside the office, regardless of the length of time that my services have terminated. I will not accept social or family event invitations from you, and do not offer same. This is not an expression of a lack of interest in you, nor any evaluation of these events.
3. At no time will I engage in any physical contact with you in our relationship, other than the shaking of hands as a greeting or parting.
4. I will not accept any gifts, including food or invitations to meals. This is not a refusal to acknowledge nor a withholding of goodwill, in seasonal or holiday greetings or well wishes to you. It is instead the recognition that professional service, offered and received, is sufficient and complete.
5. I neither accept nor provide any other services other than the practice of psychotherapy and counseling. I will not enter into any business or financial relationships with clients, other than the receipt of professional fees for service rendered.
6. To help ensure the confidentiality of your status as a client, if I see you in a public setting, I will not initiate any recognition or familiarity with you. If you choose to initiate visible or audible greeting or recognition with me, I will reciprocate, but will initiate no further exchange unless requested.
7. I will only initiate appropriate referrals to other health professionals with a client's consent. I make reasonable efforts to identify at least two professionals for each type of referral. I never accept or solicit any compensation of any kind in return for making or accepting a referral. I do not refer clients to specific attorneys, nor to accountants, financial planners or credit counselors.
8. Fragrance Policy: Please refrain from the use of any cologne, after-shave or perfume prior to future appointments. This is a courtesy to all other clients. Some clients may have allergic sensitivity to ingredients in these products.

9. Emergency Service for Critical Incidents: I am contracted with several emergency service networks that help victims of incidents that can cause emotional and psychological trauma. These include robberies, industrial accidents, large layoffs and sudden deaths. I may be called to the scene of an emergency on the same day it occurs, or a day or two after an incident.

   I must provide these services on a particular date, but make every effort to maintain my scheduled office appointments. However, if schedule changes are unavoidable, I will immediately call all affected clients to reschedule appointments.

   If called to the scene on the same day an incident occurs, I may not be able to reach you in time to prevent your coming to your scheduled appointment. The likelihood of this happening is quite small. If this does occur, your rescheduled appointment will have any copayment or coinsurance waived.

   Please also be aware that I may receive emergency text messages from these service networks at any time. This is the only interruption to our appointment that I allow. When I receive a message during an office appointment, I will notify you and then respond as briefly as possible. The interruption lasts less than two minutes, and I will make up this time to you during the appointment.