Fern Grove Counseling & Consultation PLLC
Rebecca Pope, MAEd, MAT, LMHCA
11050 Larrabee Ave., Suite 104 # 436
Bellingham, WA 98225
(360) 603-5037
Beccapope@ferngrovecounseling-wa.com
Disclosure Statement and Informed Consent
This statement is for the purpose of your rights and responsibilities for our therapeutic relationship. I am a Licensed Mental Health Counselor Associate (LMHCA) with a degree in Clinical Mental Health Counseling (MAEd) from Seattle University. I provide psychotherapy and educational consulting services in the private practice sector. This statement discloses my education, training, credentials, my therapeutic and theoretical approach, fee for services, the cancellation policy, emergencies, your rights, privacy, responsibilities, and other policies, practices, and procedures while involved in this service.
Training, Education, and Licensure
· Master of Arts in Education (MAEd) Clinical Mental Health Counseling – Seattle University – 2024
· Master of Art in Teaching (MAT) Secondary Language Arts – Lewis and Clark College – 2013
· Active Licensed Mental Health Counselor Associate - License # MC61583703, NPI # 1518833748
· I pursue training and educational opportunities relevant to my clinical practice such as neurodivergent-affirming approaches to counseling.
Client Rights and Responsibilities
My duty is to keep therapeutic practice standards in compliance with the American Counseling Association’s Code of Ethics. Core values that are relevant to this code include respect, dignity and worth of the person, service, importance of human relationships, integrity, competence, and social justice. You have the right to choose a therapist that best meets your needs and reasons for psychotherapy. You have the right to choose a treatment modality that best suits your needs. You have the right to refuse or terminate treatment at any time for any reason.
What You Can Expect
The process of counseling has both benefits and risks. Negative factors may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness. This is because the process of counseling often requires discussing unpleasant experiences in your life. Participation in services is not a guarantee of results and/or response to treatment.
Counseling requires effort from both the client and the counselor. Collaboration through the therapeutic relationship will bring a greater likelihood of success.
I am available to discuss any questions or concerns you have at any time during the therapeutic process. If you have concerns about your experience or involvement in treatment, please discuss this with me. I value being transparent, and having open, honest conversations about issues that arise.
My Approach
I provide individual psychotherapy services to adolescents (13 yrs +) and adults. My approach to counseling involves cultivating a trusting therapeutic relationship in a safe space. I believe in working towards a world that sees neurodiversity as an asset and not a hindrance. I value social justice and anti-oppression philosophies based on cultivating strength and resilience in a space of wellness.
My counseling practice is inspired by Acceptance and Commitment Therapy (ACT), Narrative Therapy, Person-Centered Therapy, and neurodivergent-affirming practices. I help clients to cultivate their stories through radical acceptance and identity empowerment. Therapy is client-centered and collaborative because I believe that the client is the expert of their own story. In this space, you can expect a neurodiversity, anti-ableist lens. Individual treatment goals are crafted in collaboration and are based on the client’s personal values.
My business is in the private practice sector and outside of the medical model. By paying out of pocket, you have greater privacy (insurance does not have access to diagnoses or dates of service) as well as freedom to choose your provider. Ultimately, insurance companies don’t get to dictate what services look like for you.
Psychotherapy services are held exclusively via telehealth at this time.
Billing Information
Cost per service:
§ Individual Psychotherapy - $120 / 50-minute session
I cannot accept insurance at this time, which means that clients must pay out of pocket for psychotherapy services with me.
The standard meeting time for psychotherapy is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session need to be discussed with the therapist for time to be scheduled in advance.
Payment is expected at the time of service; your card will be charged following the appointment. A late fee of $25 may be added if there is an overdue invoice beyond one week. If requested, I will provide you with an invoice you can use to submit to your insurance to request out-of-network reimbursement called a superbill. A good faith estimate of expected charges is available upon request.
For payment, I accept cash, credit card, debit card, or check. Your credit or debit card information may be on file. If you are experiencing financial hardship, I offer a sliding scale rate. Please be aware that I charge clients the full fee for no show, missed or late canceled sessions unless I am given at least 24-hour notice. You will be responsible for the fee if I receive notice less than 24 hours from the start of the appointments. I will wait a total of 15 minutes for your arrival from the start of the session before it is considered a no show, missed or late canceled session.
If without prior written agreement, no payment has been received for 90 days, the amount owed may be provided to a collection agency with the least personal information provided as requested from the debt processor. Identifying information may be disclosed for billing purposes to a debt collection agency if you fail to pay for services by our agreement. Non-payment may also be a basis for termination of services.
If you request a copy of your file, I may charge the fees specified in WAC 246-08-400. All record requests must be provided in writing. Under some rare circumstances, I may deny access to the record. Otherwise, the information will be released within 14 business days. Any over payment, payment adjustment, or refund required on your account will occur within 14 business days upon receiving the corrected amount in writing from the client.
The fees in this agreement are subject to change at any time and will be effective immediately upon notice to you.
Appointment Cancellation and No-Show Policy
Please remember to cancel or reschedule 24 hours in advance. You will be responsible for a $120 fee if cancellation is less than 24 hours. Cancellations and re-scheduled sessions will be subject to a full charge if not received at least 24 hours in advance. This is necessary because a time commitment is made to you and is held exclusively
If we do not receive a response from you after multiple attempts to contact you to schedule an appointment, your file will be closed. In the event that your counselor needs to reschedule or cancel an appointment with you, you will be notified by phone or email.
Should you fail to schedule and attend appointments after 4 consecutive weeks, unless arrangements have been made in advance, I will assume you wish to terminate our current episode of care, and I will consider the professional relationship discontinued. You may need to be discharged from services for excessive no shows and/or late cancellations (three during the entire course of treatment) and not scheduling a follow-up session. Failure to follow the treatment plan could result in termination of services which include but is not limited to frequency and duration of sessions which may result in discharge from treatment.
Working with Minors
If you are a parent, caregiver or legal guardian of a minor at the age of 13 years old or older, the minor’s record may not be accessible to you under law. These records as pertaining to mental health services (the age of 13 and older), substance abuse/chemically dependency services (the age of 13 and older), and sexually transmitted diseases (the age of 14 and older), unless a written authorization was provided by the minor child allowing disclosure. A safety concern or a court order may be an exception to this policy. Under certain circumstances, as a parent, caregiver and/or guardian you may be asked to review and sign the form, Waiver Attestation for Custody.
Divorce and Custody Litigation
I cannot provide a recommendation, evaluation, or opinion, in any legal forum relating to separation, divorce, child custody, visitation, or parenting plans. I do not provide my services for the purpose of preparing for legal matters including divorce, custody, or any other legal/court dispute, matter and/or proceeding, I want you to understand that I will not voluntarily provide my records, evaluations, depositions, or testimony in court.
Professional Boundaries
The therapeutic relationship should be respectful and professional. Professional boundaries are essential so that no harm is done in the therapeutic relationship. I uphold the following practices regarding professional relationship boundaries including but not limited to:
· I will not, at any time, have a relationship with you outside of my professional office location or additional location of services, even after we have ended our therapeutic, professional relationship. I will not accept any social network/media “friend” requests, and I will not communicate with you through social media websites or applications
· I will not, at any time, engage in any form of physical, sexual, or inappropriate interaction or contact with you at any time. I follow the client’s lead with comfortability and put value on bodily autonomy.
· I will not accept or receive any gifts from you.
· If we see each other outside of our meetings, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
Confidentiality
To provide clients with quality care and to comply with legal requirements, this notice applies to all the records generated by this psychotherapy practice. The following notice tells you about the ways in which I may disclose health information about clients. Your participation in psychotherapy, the content of our meetings, and any information you provide to me during our meetings is protected by legal confidentiality.
If we see each other by chance outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office
Adolescents 13 and up have the right to consent to treatment without parental involvement. When working with adolescents, I will clearly explain the limits of confidentiality with both the parents and the teen at the start of treatment if parents are involved
Some exceptions to confidentiality include the following situations in which I may choose to, or be required to, disclose this information:
· If you give me written consent to have the information released to another party.
· In the case of your death or disability I may disclose information to your personal representative
· If you waive confidentiality by bringing legal action against me.
· In response to a valid subpoena from a court or from the secretary of Washington State Department of Health for records related to a complaint, report, or investigation.
· If I reasonably believe that disclosure of confidential information will avoid or minimize an imminent danger to your health or safety or the health or safety of any other person;
· If, without prior written agreement, no payment for services has been received after 30 days, the account name and amount may be submitted to a collection agency.
· As a mandated reporter, I am required by law to disclose certain confidential information including suspected abuse or neglect of children under RCW 26.44, suspected abuse or neglect of vulnerable adults under RCW 74.34, or as otherwise required in proceedings under RCW 71.05.
· I meet regularly with my clinical supervisor Kendra Thew, PHD, MA (License # PY60820332) to discuss my counseling work. This is required by Washington state law (WAC 246-809-230 – Supervised postgraduate experience) Information concerning you will remain confidential.
Occasionally I may need to consult with other professionals in their areas of expertise to provide the best treatment for you. Information about you may be shared in this context without using your name
Records
Client records are held on a data-secure, encrypted platform called Sessions Health. Records will be destroyed 6 years after termination of the therapeutic relationship. Any physical client related records will be kept in a secure place, safeguarding from any unauthorized access.
Access to Your Record
In case I am suddenly unable to continue to provide professional services or to maintain client records due to incapacitation or death, I have designated a Professional Executor. If I die or become incapacitated, my Professional Executor will be given access to all my client records and may contact you directly to inform you of my death or incapacity; to provide access to your records; to provide professional services if needed; and/or facilitate continued care with another qualified professional if needed. If you have any questions or concerns about this professional executor arrangement, I will be glad to discuss them with you. By signing this form, you are agreeing to the terms listed here.
Electronic Communication
I cannot ensure the confidentiality of any form of communication through electronic media, including emails. If you prefer to communicate via email regarding issues of scheduling or cancellations, I will do so. Please be aware that choosing to communicate through online messages or texts is less secure than calling or leaving a message on my confidential voicemail.
If you chose to communicate via email or give me permission to do so in your intake paperwork, you are stating awareness and acceptance of the limited confidentiality for that communication. If you share information beyond scheduling or cancellations, I will do my best to read these messages and encourage us to engage with this information in our next confidential session together.
While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
Telephone Accessibility
I am unable to send or receive text messages. If you need to contact me between meetings, please leave a message on my voicemail. I am often not immediately available; however, I will generally attempt to return your call within 48 hours. If phone calls exceed 10 minutes in duration, I will charge the standard rate that applies to you located in the Cost for Service section of this agreement.
Emergencies
If you are experiencing an emergency or crisis, please call 911 or the Crisis Care Line at 988. In these situations, you may also go to the nearest emergency department.
Supervision and Video Recording
I record sessions to review with my clinical supervisor individually with a client’s consent. This is completely optional and not a required part of therapy. Video / audio recordings are encrypted and will be erased/destroyed after review by the counselor and supervisor. Your agreement to be recorded is voluntary and will not limit your ability to meet with me. Please initial your choice below:
_______ I consent to allow my session to be video recorded
_______ I consent to allow my session to be audio recorded only
_______ I do NOT consent to allow my sessions to be video or audio recorded
Termination – Closing our Work Together
The end of our therapeutic relationship could be difficult, so it is important to have a closing process. I may be ethically required to end treatment after appropriate discussion with you if I determine our work together is not effective for you or if you are in default on payment. I will generally not terminate the therapeutic relationship without first discussing the reasons for closing. Upon request, I will provide you with a list of qualified professionals to treat you. You may also choose someone from another referral source.
You have the right to terminate our therapeutic relationship at any time. As your therapist, I also may terminate therapy at any time. This may be because you have completed your therapy or that I am no longer a good fit or competent to support you. In the latter two cases, I will provide you with several referrals to continue therapy services somewhere that would be a better fit.
In any case of termination, I will give as much advanced notice as possible. I request that if you are planning to end therapy, you also give as much advance notice as possible. This gives us both time to wrap up your work. I will assume you have terminated our relationship if you did not explicitly request this, and there is no contact for 30 days. This will result in my closing your file
Additional Information
Changes to this notice are subject to change at any time. If I make changes, the new notice term will be effective immediately upon notice to you. By signing this form, you agree to the changes being made, that you have been notified, and that you have received a copy of this form.
HIPAA Notice of Privacy Practices
NOTICE:
I keep a record of the health care services I provide you. You may ask me to see and copy that record. You may also ask me to correct that record. I will not disclose your record to others unless you direct me to do so or unless the law authorizes or compels me to do so.
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.
Your health record contains personal information about you and your health. State and Federal law protects the confidentiality of this information. Protected Health Information (PHI) is information about you, including demographic information that may identify you and that relates to your past, present, or future physical and mental health, or condition, and related health care services. If you suspect a violation of these legal protections, you may file a report with the appropriate authorities in accordance with Federal and State regulations
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I am required by law to maintain the privacy of your PHI and to provide you with notice of my legal duties and privacy practices with respect to your PHI. This Notice of Privacy Practices describes how I may disclose your PHI in accordance with all applicable federal and state laws. Disclosure means the release, transfer, provision of access to, or divulging in any manner of information outside the entity holding the information.
I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will make available a revised Notice of Privacy Practices by sending you an electronic copy, sending a copy to you in the mail upon your request, or providing one to you in person.
PHI (Protected Health Information) Disclosure
For Treatment. I may use and disclose medical and clinical information about you to provide you with treatment services.
For Payment. I may use and disclose information about you so that I can receive payment for the treatment services provided to you.
For Healthcare Operations. I may use and disclose your protected PHI for certain purposes in connection with the operation of my professional practice, including supervision and consultation.
Without Your Authorization. State and Federal law also permits me to disclose information about you without your authorization in a limited number of situations, such as with a court order.
With Authorization. I must obtain written authorization from you for other uses and disclosures of your PHI
Incidental Use and Disclosure
Due to the nature of these communications and practices, as well as the various environments in which individuals receive health care or other services from covered entities, the potential exists for an individual’s health information to be disclosed incidentally.
The Privacy Rule permits certain incidental uses and disclosures that occur as a by-product of another permissible or required use or disclosure, if the covered entity has applied reasonable safeguards and implemented the minimum necessary standard, where applicable, with respect to the primary use or disclosure. An incidental use or disclosure is a secondary use or disclosure that cannot reasonably be prevented, is limited in nature, and that occurs because of another use or disclosure that is permitted by the Rule.
Disclosures That Do Not Require Your Authorization
Required by Law. I may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law.
Health Oversight. I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.
Abuse or Neglect. I may disclose your PHI to a state or local agency that is authorized by law to receive reports of abuse or neglect. However, the information we disclose is limited to only that information which is necessary to make the required mandated report.
Disclosures of PHI With Your Written Authorization
Other uses and disclosures of your PHI will be made only with your written authorization. I will not make any other uses or disclosures of your psychotherapy notes, I will not use or disclosure your PHI for marketing purposes, and I will not sell your PHI without your authorization. You may revoke your authorization in writing at any time. Such revocation of authorization will not be effective for actions I may have taken in reliance on your authorization of the use or disclosure. You may revoke such authorizations in writing in accordance with 45 CFR. 164.508(b)(5).
Your Rights Regarding Your PHI
You have the following rights regarding PHI that I maintain about you. This list is not exhaustive. Any requests with respect to these rights must be in writing.
Right of Access to Inspect and Copy -You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as I maintain the record. A "designated record set" contains medical and billing records and any other records that I use for making decisions about you. Your request must be in writing.
Right to an Accounting of Disclosures -You may request an accounting of disclosures made for treatment purposes or made because of your authorization, for a period of up to six years, excluding disclosures made to you. I may charge you a reasonable fee if you request more than one accounting in any 12-month period. Please contact me if you have questions about accounting of disclosures.
Right to Request Confidential Communication -You have the right to request to receive confidential communications from me by alternative means or at an alternative location. I will accommodate reasonable written requests. I may also condition this accommodation by asking you for information regarding how payment will be handled or specification of an alternative address or other method of contact. Please contact me if you would like to make this request.
Right to a Copy of this Notice -You have the right to obtain a copy of this notice from me. Any questions you have about the contents of this document should be directed to me.
Right to Notice of Breach -You have the right to be notified of any breach of your unsecured PHI.
Contact Information
I act as my own Privacy and Security Officer. If you have any questions about this Notice of Privacy Practices, please contact me. My contact information is:
Fern Grove Counseling & Consultation PLLC
11050 Larrabee Ave., Suite 104 # 436
Bellingham, WA 98225
(360) 603-5037
Beccapope@ferngrovecounseling-wa.com
Complaints
If you have concerns about your experience or involvement in treatment, please reach out to me directly. I value transparency and am always open to discussing issues. A copy of the acts of unprofessional conduct can be found in RCW 18.130.180. If you feel that I have been unethical or unprofessional, you may contact the Washington State Department of Health, HSQA Complaint Intake. The mailing address is P.O. Box 47857 Olympia, WA 98504-7857 or you may call them at 360-236-4700. You may also access forms and information at www.doh.wa.gov/hsqa.
Effective Date
Effective date of this notice: January 20, 2026
Client Signature, Acknowledgment, Agreement, and Informed Consent for Treatment
I have received a copy of this document. I have read and understand this Disclosure Statement and Informed Consent for treatment, and that I have received a copy of my HIPAA Notice of Privacy Practices. I have had the opportunity to ask questions regarding this material, and I understand fully this agreement. My participation is voluntary, and I am personally responsible for my experience. By signing this form, I agree to all the information in this agreement, and I am making an informed consent to Psychotherapy services with Rebecca Pope, MAEd, LMHCA according to the terms listed here.
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Client Name(s) DOB Date
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Client Signature
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Psychotherapist Signature Date