Lisa Waugh, MA, LMHC Affiliate of Northwest Family Life
 5224 Olympic Dr. NW, Ste. 101 Gig Harbor, WA 98335 
6512 20th St. Ct. W., Ste. B-1, Fircrest, WA 98466 
360-649-9859 
lwaugh@nwfamilylife.org

PERSONAL DISCLOSURE STATEMENT & CONSENT FOR TREATMENT
PROFESSIONAL CREDENTIALS
Washington State Licensed Counselor 

IDENTITY AND THEORETICAL ORIENTATION
Welcome to my practice. I appreciate your giving me the opportunity to be of help to you. This brochure answers some questions clients often ask about any therapy practice. It is important to me that you know how we will work together. I believe our work will be most helpful to you when you have a clear idea of what we are trying to do.
I am a mental health counselor with a Master’s degree in Existential Phenomenological Psychology from Seattle University and a Bachelor’s degree from the University of Washington. I have extensive experience with grief and loss, family relationships, adolescents, and life-threatening illness. My counseling approach includes cognitive behavioral, mindfulness and phenomenological methods.
Cognitive behavioral psychotherapy challenges negative patterns of thought about the self and the world in order to alter unwanted thought/behavior patterns.
Mindfulness is a state of active, open attention on the present, where thoughts and feelings can be observed without judgment. Mindfulness allows us to live in the moment and awaken to experience.
Phenomenology is an approach that concentrates on consciousness and direct experience.
Counseling is a relational context, which provides the safety and support needed for healing and growth. Counseling is a shared experience, with both counselor and client(s) contributing to its effectiveness. You can expect to be heard without judgment.
By the end of our first or second session, I will tell you how I see your case at this point and how I think we should proceed. I view therapy as a partnership between us. You define the problem areas to be worked on; I use some special knowledge to help you make the changes you want to make. Psychotherapy is not like visiting a medical doctor. It requires your very active involvement. It requires your best efforts to change thoughts, feelings, and behaviors. For example, I want you to tell me about important experiences, what they mean to you, and what strong feelings are involved. This is one of the ways you are an active partner in therapy.
An important part of your therapy will be practicing new skills that you will learn in our sessions. I will ask you to practice outside our meetings, and we may work together to set up homework assignments for you. I might ask you to do exercises, to keep records, and perhaps to do other tasks to deepen your learning. You will probably have to work on relationships in your life and make long-term efforts to get the best results. These are important parts of personal change. Change will sometimes be easy and quick, but more often it will be slow and frustrating, and you will need to keep trying. There are no instant, painless cures and no “magic pills.” However, you can learn new ways of looking at your problems that will be very helpful for changing your feelings and reactions.
I invite you to ask questions and discuss my counseling approach with me. You have the right to refuse counseling treatment. You also have the responsibility to choose the counselor and type of therapy that best suits your needs. Counselors have different styles and if you feel the approach being used is not right for you, please discuss your concerns with me. Counseling occurs over a number of weeks or months, and at times, more than a year. Each counselor and client, according to her/his best judgment, negotiates the exact length of the counseling relationship. I encourage you to ask questions about the orientation being used, the treatment plan, and any other matters. In the event that I am unable to meet your needs, I will provide a referral for you. You have the right to end therapy at any time without additional obligation other than that already incurred.
OFFICE POLICIES
My customary hourly fee is $150.00. Charges for extended appointments will be assessed according to the hourly rate. This also includes between-session telephone calls lasting longer than 5 minutes. Further, if you and I agree that it would be helpful for me to consult with another paid professional regarding your situation you will be responsible for all fees, including my time. In the event that I receive a subpoena to testify in any court proceedings, a charge for mileage of 55¢ per mile and any parking fees will also be assessed. My Financial Policy is part of this package and outlines my fees and provides information about billing and insurance. Please read it carefully.
Financial considerations are a necessary part of counseling. Openness and flexibility are needed when determining a client’s financial obligation. It is my policy not to let a client accrue a balance of more than $290.00 in personal debt. If at such time your balance goes beyond that amount, reasonable efforts must be made to reduce your balance before continuing counseling.
Appointments: A typical session lasts 50 minutes. At times, it may feel that a session ends abruptly, but just as I will end the appointment before yours, so as not to keep you waiting, I ask that you recognize that I must end on time to be ready for my next client. If you will not be able to attend an appointment, please call 360-649-9859 to notify me of your cancellation 24 hours in advance of your appointment. You will be charged a $50.00 fee if cancellation is not received with proper notice. If you miss an appointment, without cancelling ahead of time, you will be charged the full fee and a future appointment will not automatically be scheduled for you. I will wait to hear from you to reschedule. If you do not arrive within 15 minutes following your scheduled appointment time, your session is considered cancelled and payment may be required. If you arrive late, our session will end one hour from the scheduled start time. Please initial here to signify you understand and accept this policy. _____________
In the event of my absence (vacation or illness) you will be notified if it conflicts with a scheduled appointment. In case of an emergency, please call Pierce County Crisis Line at 253-798-4333 or the Mental Health Crisis Line at 206-461-3222.
CONFIDENTIALITY
The counseling relationship is a confidential one. Anything you share with me will be kept in confidence. I will keep no secrets between couples and family members when all members are clients.
Disclosure of information about you to anyone requires your written consent. However, as a counselor, I am legally and ethically obligated to release information in the following situations:
A. As required by law (RCW 70.02.050
1. When there is a threat of risk of self-harm (suicide), or harm to another person (homicide). 2. When there is “reasonable cause” to suspect abuse or neglect of a child, disabled, or elderly person from anything reported in a counseling session. 3. If I receive a subpoena from a court of law.
Professional Consultation: As part of my professional responsibility, I occasionally consult with colleagues, and I may receive clinical supervision from qualified supervisors. A record of counseling services is kept in the office. You may ask to see the record and have a copy for a nominal fee. If you wish to have no records kept, please request that in writing and I will keep only the minimum information required by Washington law. My Notification of Privacy Practices is a separate document in this package that provides additional detail about how your protected health information may be used and how to request a copy of your file.
ETHICAL AND PROFESSIONAL STANDARDS
I subscribe to the ethical and professional standards of the Washington State Licensing Law. If you have questions about or work together, please talk with me about this, so that we can come to an understanding about your specific needs and the direction of our work together. In the event that you feel I have acted in an unethical manner, please discuss the situation with me so that we can come to a resolution. If you find that our negotiation has not been satisfactory, you may contact directly, the U.S. Secretary of Health and Human Services.
Counselors practicing counseling for a fee must be licensed with the Department of Health for the protection of public health and safety. Registration of an individual with the department does not include recognition of any practice standards, nor necessarily imply the effectiveness of any treatment.
WHAT TO EXPECT FROM OUR RELATIONSHIP
As a professional, I will use my best knowledge and skills to help you. As part of my effort to maintain your privacy, I may not say hello or talk to you very much if we meet on the street or in a social setting. My behavior will not be a personal reaction to you, but a way to maintain the confidentiality of our relationship. In your best interest, and following ethical standards, I can only be your therapist. I cannot have any other role in your life. I cannot, now or ever, be a close friend or socialize with any of my clients. I cannot be a therapist to someone who is already a friend. I can never have a sexual or romantic relationship with any client during, or after, the course of therapy. I cannot have a business relationship with any of my clients, other than the therapy relationship.
Even though you might invite me, I will not attend your family gatherings, such as parties or weddings. As your therapist, I will not celebrate holidays or give you gifts; I may not notice or recall your birthday; and may not receive any of your gifts eagerly.

EMERGENCY SERVICES
I do not provide emergency or 24 hour service. In an emergency, you should call 911, the Pierce County Crisis Line at 253-798-4333, Mental Health Crisis Line at 206-461-3222, medical services or other appropriate agencies.
SIGNED CONSENT
Your signature below indicates that you have read and were offered a copy of this document, my Financial Policy, Notification of Privacy Practices, as well as the opportunity to clarify any questions you have pertaining to this document.
My signature indicates the accuracy of the information with this document and my declaration to uphold the conditions listed within. Any exceptions or additions to this disclosure statement appear below.
__________ _______________________ _______________________________ Date Printed Name Signature
___________ _______________________ _______________________________ Date Printed Name Signature

CONSENT FOR TREATMENT OF MINOR
I/We consent that ___________________________ may be treated by Lisa Waugh, MA, LMHC

___________ _______________________ _______________________________ 
Date 			Printed Name 			Signature

____________ ______________________________
 Date 			Lisa L. Waugh, MA, LMHC