DISCLOSURE STATEMENT

You can print out directly from this page and sign it, indicating you have read this disclosure statement prior to your appointment and bring it with you.

In 1987 I became associated with Northwest Youth Services and had specialized training to include the licensing of foster homes. I have had training and experience leading groups of parents and adolescents. I opened my private practice in Bellingham in January 1989, specializing in working with at-risk adolescents who had special needs for mental health counseling. In addition to my work with youth, I have worked with women with eating disorders and women with chronic depression. I worked at Whatcom Psychiatric & Counseling Clinic for 10 weeks in 2004 on the Youth Team, and refreshed my mental health skills with that population. My private practice was closed from the end of 2000 until December 2004, but is now open full-time and known as Fairhaven Counseling.

In January of 2005 I spent 30 hours of intense therapist-core training with the WA Coalition of Sexual Assault Programs. My education includes a BA degree in Psychology from the University of Puget Sound in Tacoma, and a MA in Psychology from Antioch in Seattle in June 1988 with a concentration in Counseling and Psychotherapy.

Counselors practicing counseling for a fee must be registered or certified with the Department of Licensing for the protection of the 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 (WAC 308-190-040).

In order to become a licensed mental health counselor I was required to document appropriate course work leading to a Master’s degree in Psychology from an accredited university. In addition, I documented 2,000 hours of supervised psychotherapy.

My practice of counseling is best described as multi-modal. This means that I listen carefully to the individual needs of my clients. My practice is based on my entering into a relationship with my client that is honest and committed to serving the specific needs of the client. My practice draws from the work of Carl Rodgers, Murray Bowan, Carl Whittaker and Alice Miller. I regard feelings that come up about the therapy process as important to discuss. I encourage clients to work at a pace that is comfortable for them and to be as open with me as they can be. If a client feels, at any time, that another therapist might be more suitable or more appropriate I am happy to make referrals. I understand that at times a change in therapist or counselor may be a positive plan, and I do not want any client to feel that such a request is difficult to make.

Client Responsibilities:

1. To make financial arrangements prior to first session. I operate on a sliding fee schedule and it is negotiated on a case-by-case basis.
2. To arrive on time for each counseling session, and to be willing to end the session on time. The planned time for each session will be 50 minutes.
3. I expect payment for any session that is missed without 24-hour notice, unless there is an emergency.

Therapist Responsilities:

1. To follow all professional practices and conduct.
2. To absolutely respect the confidentiality and trust of each client. The only exceptions are child abuse, homicidal intent, or the intent to do oneself bodily harm.
3. To consult with your MD or other professionals as it is appropriate to your therapy, but only with your written permission. (See the above mentioned 3 exceptions.)
4. I am available to you through the use of my voice mail, which I check frequently. In addition, I want you to be aware of the Whatcom County Crisis Line at 1-800-584-3578 and the Whatcom Counseling and Psychiatric Clinic at 676-2220. You can always drive to St. Joseph’s Hospital emergency room and ask for a psychiatric evaluation at any time if you are feeling out of control. If I receive an urgent message from you I will make every attempt to return the call as soon as I am able to, but please make use of these other resources and options so you are not left feeling alone in an emotional emergency.

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Client Signature & Date

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Therapist Signature & Date

WAC 246-810-035 requires that a counselor providing professional services to a client or providing services billed to a third party payer, shall document services, except as provided in subsection (2) of this section. The documentation shall include:

1. client name
2. the fee arrangement and record of payments
3. dates counseling was received
4. disclosure form, signed by client and counselor
5. the presenting problem(s), purpose and diagnosis
6. notation and results of formal consults, including information obtained from other persons or agencies through a release of information
7. progress notes sufficient to support responsible clinical practice for the type of theoretical orientation/therapy the counselor uses.

It is your right under the law to request that only items a through d above be kept in the form of written records. If you desire to make this request, fill in the following.

I _________________________________ hereby request that Shirley Lange, MA keep no notes or records regarding items e through g above as provided in WAC 246-810-035, subsection 2.

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Client Signature & Date

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Therapist Signature & Date