Disclosure and Office Policies Agreement

Sandra Roscoe, PhD, LMFT
For Teletherapy, please contact:

[email protected]


1996                            Doctor of Philosophy - Marriage and Family Therapy

Dissertation Title:

Mind/Body Conversations: Hypnosis, Meditation, & Poetry

Nova Southeastern University, Ft. Lauderdale, FL

1991                            Master of Science - Marriage and Family Therapy

Nova University, Fort Lauderdale, FL

1989                            Bachelor of Science - Psychology
Nova University, Fort Lauderdale, FL


1998   A Relational Approach to Hypnotherapy Training: 50 hours

1994    Sixth International Approaches to Hypnosis & Psychotherapy:

Hypnosis training: 30 hours

1993    The American Society of Clinical Hypnosis: 20 hours

1992    The Fifth International Congress on Ericksonian Approaches to Hypnosis

and Psychotherapy: 44 hours

1991    Second Eastern Conference on Ericksonian and Hypnosis and Psychotherapy: 20 hours


Feb 2012 – Present Family Therapist, Ph.D., LMFT

Private Practice , Seattle, WA.

May 2007- Feb 2012 Family Therapist, Ph.D., LMFT

Private Practice, Lynnwood & Edmonds, WA.

May 99 - April 2007 Family Therapist, Ph.D., LMFT

Private Practice, Spruce Pine, N.C.

Dec. 96 - May 99 Family Therapist, Ph.D., LMFT

Private Practice, 2699 Stirling Road, Fort Lauderdale, FL

May 97 - Present AAMFT Approved Supervisor

Aug 91 - Dec 95 Family Therapist, M.S., LMFT

Private Practice , 2699 Stirling Road, Fort Lauderdale, FL

THERAPEUTIC ORIENTATION: I provide individual, couples, and family counseling.  My treatment specialization includes:

• Relationship issues

• Conflict Resolution

• Grief

• Loss

• Anxiety

• Depression

• Pain Management

• Life Transitions

• Family-of-Origin Issues

• Eating Disorders

• Work and Career Issues

I currently work with a broad spectrum of clients utilizing brief, solution focused, cognitive behavioral, and family systems therapies. I work with a wide range of emotional and behavioral issues providing services that span from therapy for depression and grief counseling to parenting support, couples counseling, and beyond.  In a comfortable and supportive atmosphere, I offer a highly personalized approach tailored to my clients’ individual needs to help them achieve the personal changes they’re striving for . My approach is pragmatic and goal oriented.

FINANCIAL REQUIREMENTS: Clients are expected to pay the standard fee of $140.00 per 60-minute session at the end of each session. Telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify me if any problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, I will provide you with a copy of your receipt after each session or on a monthly basis, which you can then submit to your insurance company for reimbursement, if you so choose. As is indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems dealt with in psychotherapy are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. If your account is overdue (unpaid) and there is no written agreement on a payment plan, I can use legal or other means (courts, collection agencies, etc.) to obtain payment.

HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct me, only the minimum necessary information will be communicated to the carrier. Your therapist has no control over, or knowledge of, what insurance companies do with the information she submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and is likely to be reported to the National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access.  Medical data has been reported to be legally accessed by law enforcement and other agencies, which may also put you in a vulnerable position

CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.

WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client's family members communicate to me that the client presents a danger to others. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by me. In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. I will use my clinical judgment when revealing such information. I will not release records to any outside party unless s/he is authorized to do so by all adult parties who were part of the family therapy, couple therapy or other treatment that involved more than one adult client.

EMERGENCY: If there is an emergency during therapy, or in the future after termination, where I am concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, I may also contact the person whose name you have provided on the biographical sheet.

LITIGATION LIMITATION: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that, should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney(s), nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.

CONSULTATION: I regularly consult with other professionals regarding my clients; however, each client's identity remains completely anonymous and confidentiality is fully maintained.


HIPPA compliant: HIPPA requires that any platform used for Telehealth services have a Business Associate Agreement (BAA) between the healthcare provider and the technology company. The BAA must guarantee that all security practices and data encryption are HIPPA compliant. The Doxy.me Telehealth platform used in this practice meets these requirements.  However, because of the use internet services there can still be a breach of private information.  Clients and therapists are responsible to limit the risk of privacy breaches with respect to the technology they are using (computers, phones, iPads, etc.).

Payment: Washington’s parity mandates payment for teletherapy services at the same rates as in-person care under private insurance, state employee health plans, and Medicaid managed care.  This law applies to live video and telephone sessions.

Confidentiality & teletherapy: Your right to confidentiality is under the same law as in-person psychotherapy.

Outcome differences: Research has demonstrated that teletherapy services provide the same-level client care as face-to-face therapy, and that there is no outcome difference found between teletherapy and face-to-face therapy. However, there is no guarantee that all treatment for all clients will be effective.

Risks to teletherapy services: Unique risks specific to teletherapy include, but are not limited to, the possibility that therapy sessions could be disrupted or distorted by technical failures or could be interrupted by unauthorized persons.  Clients are responsible for securing private space where sessions can remain confidential and not be overheard.  Headphones are recommended.  Recording sessions is discouraged in order to protect privacy.

Another risk (or limitation) to teletherapy services: There may be times when you are better served to meet a therapist face-to-face. Some people may find it difficult to connect using teletherapy platforms. Also, because teletherapy doesn’t provide emergency services, there may be times where you would be better served to meet with a therapist face-to-face. This should be discussed with your therapist, and, when necessary, appropriate referrals given.

If you have an emergency, please call 911

Benefits of teletherapy: This includes being able to meet with a therapist who you would not be able to meet face-to-face due to an environmental crisis/pandemic. There is also the convenience of avoiding travel time (traffic, parking) and more flexibility in scheduling sessions.

E–MAILS, CELL PHONES, COMPUTERS, AND FAXES: It is very important to be aware that computers and email communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Faxes can be erroneously sent to the wrong address. Emails, in particular, are vulnerable to unauthorized access due to the fact that Internet servers have unlimited and direct access to all emails that go through them. It is important that you be aware that emails, faxes, and important texts are part of the medical records. Additionally, my emails are not encrypted. My computers are equipped with a firewall, a virus protection, and a password and I also back up all confidential information from my computers on a regular basis. Please notify me if you decide to avoid or limit in any way the use of any or all communication devices, such as email, cell phone, or faxes. If you communicate confidential or private information via email, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email. Please do not use email or faxes for emergencies.

RECORDS AND YOUR RIGHT TO REVIEW THEM: Both the law and the standards of my profession require that I keep treatment records for at least eight (8) years. Unless otherwise agreed to be necessary, I retain clinical records only as long as is mandated by Washington law. If you have concerns regarding the treatment records, please discuss them with me. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when I assess that releasing such information might be harmful in any way. In such a case, I will provide the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, and upon your request, I will release information to any agency/person you specify unless I assess that releasing such information might be harmful in any way.  When more than one client is involved in treatment, such as in cases of couple and family therapy, I will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.

TELEPHONE & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message at the answering service (206) 947-6018 and your call will be returned as soon as possible. I check my messages a few times during the daytime only, unless I’m out of town. I check my email multiple times a day. If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away, please call Psychiatric Emergency Services. Seattle (King County): ( 206) 731-3036 , the 24-hour crisis line Seattle (206) 461-3222 or t he Police: 911 . Please do not use email or faxes for emergencies.

MEDIATION & ARBITRATION: All disputes arising out of, or in relation to, this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement by the client(s) and me. The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in King county, Washington in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed.  Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, I can use legal means (court, collection agency, etc.) to obtain payment.  The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorney's fees. In the case of arbitration, the arbitrator will determine that sum.

THE PROCESS OF THERAPY / EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. I will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which may cause you to feel upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes another family member may view a decision that is positive for one family member negatively. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, it is likely that I will draw on various psychological approaches according, in part, to the problem being treated and my assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, cognitive, family systems, individual and family developmental (adult, child, family), humanistic or psycho-educational. I do not provide custody evaluation recommendations, medications, prescription recommendations nor legal advice, as these activities do not fall within my scope of practice.

TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, I will discuss with you my working understanding of the problem, treatment plan, therapeutic objectives, and my view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, possible risks, or my expertise in employing various methodologies or treatment plans, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.

TERMINATION : As set forth above, after the first couple of meetings, I will assess if I can be of benefit to you. I do not accept clients who, in my opinion, I cannot help. In such a case, I will give you a number of referrals that you can contact. If at any point during psychotherapy, I assesses that I am not effective in helping you reach your therapeutic goals or that you are non-compliant, I am obligated to discuss it with you and, if appropriate, to terminate treatment. In such a case, I will give you a number of referrals that may be of help to you. If you request it and authorize it in writing, I will talk to the psychotherapist of your choice in order to help with the transition. If, at any time, you want another professional's opinion or wish to consult with another therapist, I will assist you with referrals, and, if I have your written consent, I will provide her or him with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, and if appropriate, I will offer to provide you with names of other qualified professionals.

COMPLAINTS: If at any time you feel that you have been treated unethically, please let me know. If talking with me does not bring a satisfactory solution to the problem, you have the right to contact the following Boards: a) Washington Association for Marriage and Family Therapy
P.O. Box 2276
Bellingham, Washington 98227
Phone: Toll-free 1-888-553-1228
Fax: 1-888-553-1228
Email: [email protected] or b) The Washington State Department of Health http://www.doh.wa.gov/LicensesPermitsandCertificates/FileComplaintAboutProviderorFacility.aspx Health Systems Quality Assurance Complaint Intake
P.O. Box 47857
Olympia, WA 98504-7857; Local: 360-236-4700; Email: [email protected]

I have read the above Office Policies and General Information, Agreement for Psychotherapy Services or Informed Consent for Psychotherapy carefully (a total of 6 pages); I understand them and agree to comply with them:

Client's Name (print) __________________________________________________________

Signature ______________________________________________ Date ___________________

Client's Name (print) ___________________________________________________________

Signature ______________________________________________ Date ___________________

Psychotherapist's Name (print) _________________________________________________

Signature _ _________________

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