Eileen Stein, MSSW, LICSW, ACSW
1818 Westlake Avenue North Suite 124 Seattle, WA 98109
206 937-3972 (office) / 206 937-4048 (fax)
Disclosure Statement
Welcome! This Disclosure Statement is intended to provide you with information about me as a clinical therapist in hopes that I will best suite your needs for therapy.
My formal training and practice is primarily in Cognitive Behavioral Therapy. However, I draw on other theories and practice methods and models as appropriate making my clinical skills and abilities very eclectic. I believe that Cognitive Behavioral Therapy is very practical and effective for short term, solution focused treatment. Ultimately, I base therapy and clinical practice on what is best suited for each individual client.
I have over seventeen years of clinical experience with specific work in health care, mental health, cancer care, infertility, high-risk pregnancy, grief and loss, trauma and abuse. I work with individuals, couples, and groups. As a therapist I provide an environment which is safe and confidential, and where my clients can feel validated, heard, and receive support, compassion, and where clients can learn a variety of skills and gain incite which will help them to heal and lead more healthy lives.
Education and Experience:
Master of Science in Social Work University of Wisconsin-Madison (1985-1986)
Bachelor of Arts in Social Work University of Wisconsin-Madison (1981-1985)
Fee Information and Payment Policies: The initial therapy session is 55 minutes long and is billed at $120.00. Thereafter, individual therapy sessions are 50 minutes long and billed at $100.00. Couples and Family therapy sessions are 50 minutes long and billed at $110.00.
If a client requests written treatment reports or evaluations to be sent to individuals or agencies, the client will be billed for the time to complete such reports. This fee will be negotiated upon request of this particular service.
I am currently a provider for several insurance panels including, Atena, First Choice, Medicare Part B, and Molina Healthy Options. If your insurance allows, I can also bill as a non-participating provider at that specific reimbursement/patient responsibility rate/percentage. Please be advised that until I am a provider for a specific insurance company you will be responsible for therapy session fees in full. Also, once your insurance benefits/sessions run out, should you continue your therapy work with me, a private fee will be charged to you. Note that co-pays are due at each session. I accept checks made out to: Eileen Stein, MSSW, LICSW, I also accept cash, and VISA and Mastercard. Receipts are provided upon request.
If you do have insurance, it is your responsibility to get pre-authorization for mental health services if so required by your insurance carrier. If you do not get pre-authorization and your insurance does not cover the treatment, you will be responsible for the bill. I will be responsible for getting additional sessions authorized per your specific insurance policy plan.
If you have received authorization for therapy from your insurance company, but for some reason your insurance fails to provide payment, I will attempt to advocate for you to be reimbursed in any manner that I am able. However, if your insurance ultimately denies payment, you will be responsible for the full cost of services rendered. If you, the client, are under 18 years of age, your parent(s) or legal guardian is/are responsible for the bill.
If you do not have insurance or choose not to use your insurance, the full fee is due at each session unless we negotiate an individual payment plan. I do respect that not all clients are able to afford the full fee for therapy services. I see therapy as a necessary part of growth and healing...I do not see therapy as a luxury. Therefore, if you do not have insurance (or if I am not a provider for your insurance) and you are unable to pay the full fee for therapy, I am willing to provide a sliding scale figure on a case by case basis. You and I will negotiate and have in writing a payment contract which is clear and set. Since I am willing to negotiate a sliding scale with my clients, I expect that they be honest in letting me know how much they truly can and cannot afford and be willing to pay a reasonable fee for their therapy services. I believe that when a client pays a reasonable fee for their therapy, they commit to their therapy positively and seriously.
Cancellation Policy: If you need to cancel an appointment you must give me at least 24 hours cancellation notice, otherwise you will be charged the full session fee. Insurances will not pay for missed appointments. Emergency situations may be discussed with me on a case by case basis.
Emergencies: In case of an emergency, after hours, weekends, and when you are unable to reach me directly, please call the 24-hour Crisis Clinic at 206 479-3033 or 1-800-843-4793, 911 or go to the nearest hospital emergency room. If you think your current situation will involve a great need for crisis intervention or after-hours response, you may wish to choose another therapist, as my availability is limited.
Confidentiality: I am bound by my professional ethics to protect client rights to confidential communication in regards to their involvement in therapy. For this reason, if you want me to release information about your participation in therapy to anyone, I will require a signed “Release of Confidential Information”. This confidentiality has the following exception(s) as provided by law.
• In the event of a medical emergency, emergency personnel or services may be given necessary information.
• In the event of a threat of harm to oneself or someone else, if that threat is perceived to be serious, the proper individuals must be contacted. This may include the individual against whom the treat is made.
• In the event of suspected child abuse, the proper authorities must be contacted. Actions do not have to be witnessed in order to be reported.
• If ordered by a judge or other judicial officers, information regarding your treatment must be disclosed.
• If you bring a complaint against me with the State of Washington , or Department of Health, information will be released.
• If records are subpoenaed by an attorney in the State of Washington , they will be released unless you file a Protection Order within 14 days of the subpoena.
• In the event of a client's death or disability, the information may be released if the client's personal representative or the beneficiary of an insurance policy on the patient's life signs a release authorizing disclosure.
• In the event the client reveals the contemplation or commission of a crime or harmful act, the therapist may release that information to the appropriate authorities.
• In the case of a minor client, information indicating that the client is/was the victim of a crime may be released to the proper authorities.
• If the client chooses to use health insurance, the name and some information about the diagnosis and treatment are usually required. Many managed health care policies will require regular progress reports to be submitted and often to the primary care physician.
• If the client does not pay for services rendered and the account is turned over to a collection agency, some identifying confidential information will be released.
• The therapist may seek consultation or clinical supervision with other mental health professionals, but the client's identify will not be revealed. The law pertaining to confidentiality will also strictly bind any consultant or supervisor utilized for consultation.
Review of Records: I keep a record of therapy services that I provide to you. You have the right to see and copy your record. You may also ask to correct the record. I may charge a fee for photocopying any portion of your record. Please consider that reviewing your record might raise questions or concerns. For this reason, it is my clinical belief that you read your record while I am present so that I might explain or provide information regarding any questions or concerns that you might have.
Notice to Clients: As required by RCW 18.130.080, this will inform clients of certified, registered, or licensed counselors in the State of Washington that they may file a complaint with the Department of Health at any time they believe a counselor has demonstrated unprofessional conduct. Counselors practicing counseling for a fee must be registered or licensed with the Department of Health for the protection of public health and safety. It is every clients right to refuse treatment at any time, with or without notice to the therapist.
Registration of an individual with the Department does not include recognition of any practice standards, nor necessarily imply the effectiveness of any treatment. Questions or complaints my be directed to:
Department of Health
Business and Professional Administration
P.O. Box 9012
Olympia , WA 98504-8001
(360) 753-1761
I am a solo practitioner, one of a number of subtenants who share limited common facilities at a common address.
Please Complete/Sign Below:
I hereby authorize Eileen Stein, MSSW, LICSW, to provide counseling/psychotherapy services as requested as evidenced by my signature below. I have read and understand this disclosure statement and had an opportunity to have any questions answered to my satisfaction. A copy of this Disclosure Statement has been provided to the client. If I am requesting that my insurance be billed for therapy services, by signing below, I authorize payment of insurance benefits to this provider for therapy session by my insurance plan/company.
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Client Date
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Therapist Date
Eileen Stein, MSSW, LICSW 1818 Westlake Avenue North, Suite 124, Seattle, WA 98109, 206 937-3972