Molly Simkins Sluk, M.A., LMFT
Licensed Marriage and Family Therapist. License Number: LF60402154
3400 Harbor Ave SW, Ste. #203, Seattle, WA 98126
Phone: (206) 790-2364; Fax: (888) 972-7936
New Client Packet
Welcome. I look forward to our first meeting. This New Client Packet contains a number of documents I
am responsible for providing to new clients. Please take some time to review the materials in this
packet. You are welcome to complete the forms in this packet prior to or during our first meeting. At our
first meeting, we will have time to review and discuss the information presented in this packet. Please
do not hesitate to ask questions or bring up concerns at our first meeting or anytime in the future. I look
forward to working with you.
-Molly Simkins Sluk
The following forms are contained within this packet:
Clinician Disclosure Statement
Notice of Privacy Practices
Use of Email and Texting Informed Consent
Minimum Record Keeping Agreement
New Client Registration
Molly Simkins Sluk, M.A., LMFT, ATR
Licensed Marriage and Family Therapist. License Number: LF60402154
Registered Art Therapist. Registration Number: 14-086
3400 Harbor Ave SW, Ste. #203, Seattle, WA 98126
Phone: (206) 790-2364; Fax: (888) 972-7936
Clinician Disclosure Statement
Welcome
This disclosure statement is intended to inform you of my background, experience, theoretical
orientation, and approach to therapeutic services. This document is meant to help you be an informed
consumer about these aspects of my clinical practice and your rights as a client. Please don’t hesitate to
ask questions or bring up any concerns you might have now or anytime in the future. I look forward to
working with you.
State Licensure
Mental health professionals practicing therapy for a fee must be licensed with the Washington
Department of Health for the protection of the public health and safety. I am licensed by the
Department as a Marriage and Family Therapist (LMFT). My LMFT number is LF60402154. Licensure
indicates that a practitioner has met basic education, competency, and supervision standards; however,
it does not endorse a practitioner’s particular approach to therapy, nor does it imply the necessary
effectiveness of that approach.
Education and Training
I earned my Masters of Arts in Psychology from Antioch University Seattle’s School of Applied
Psychology. My degree specializations were in Couple and Family Therapy and Art Therapy. As part of
my graduate training I completed a 15 month internship at a local community mental health agency
serving children and families healing from sexual abuse. My professional experience also includes work
as a family therapist for a local Native American community as well as work in my private practice.
In addition to my training in Couple and Family Therapy, I am also an Art Therapist and am trained in
many evidence based practices including Trauma-Focused Cognitive Behavioral Therapy, Parent Child
Interaction Therapy, and Motivational Interviewing. My therapeutic approach is eclectic and I draw from
all of these models in order to best support you in reaching your goals.
I earned my Bachelor of Arts degree in Psychology and Art Therapy from Edgewood College in Madison,
WI. I am a member of the American Association for Marriage and Family Therapy. In order to provide
best client care, I receive regular supervision and participate in a psychotherapy consultation group. I
also regularly attend continuing education courses, which is a required aspect of maintaining licensure
with the Department of Health.
Therapeutic Approach
My practice involves working with individuals, couples, and families. I approach therapy from a
humanistic and systemic perspective, taking into account an individual’s unique life experiences and as
well as their relationships in family, community, and society. I am particularly sensitive to the ways an
individual’s identity regarding gender, age, race and ethnicity, sexual orientation, class background,
disability, and country of origin influences the messages they receive from society and in turn, the ways
they may think and feel about themselves.
Clinician Disclosure; Molly Simkins Sluk, M.A., LMFT / 1
During therapy sessions, I will listen carefully to your stories and experiences. I will likely ask questions
about your relationships and life experiences—past and present. I will invite you to explore the
messages you have internalized about yourself, relationships, and the world so that you can fully choose
which beliefs you wish to hold close and which ones you choose to release. I typically think of problems
or unhelpful behaviors as stemming from past hurts or unmet needs an individual holds. I will guide you
in identifying and dealing with those hurts and needs so you have more freedom and flexibility in
resolving present challenges or problematic behaviors.
Based on client interest, I may invite you to explore topics with art materials as well as through
traditional talk therapy. The creative process can often help people connect with themselves, feel
deeply, and access things that feel beyond words. No artistic experience or skill is required to participate
in or benefit from Art Therapy.
Scheduling
We will initially schedule an intake appointment that will include completion of new client paperwork
and discussion of your needs and goals as well as a plan for treatment. I meet with most clients on a
weekly or biweekly basis. Sessions are 50-55 minutes long unless otherwise arranged.
Fees
The fee for an Individual, Couple, or Family Therapy session is $120. Unless there is a prior arrangement,
full payment is required by the end of each appointment. Payments can be made by cash, check, or
credit card. There is a $25.00 fee for returned checks. If financial hardship is a concern, please speak to
me about this during our first phone conversation. Fees may change in the future; if so, I will provide a
minimum of 30 days notice. A fee of $30.00 per 15-minute increment is charged for phone calls,
collateral contacts, and report writing provided on behalf of clients.
Insurance
I am an in-network preferred provider for Premera, Regence, First Choice Health, United HealthCare,
and Group Health PPO. I am an out-of-network provider for Aetna and some other insurance plans. If I
am not able to bill your insurance directly, I am able to provide you with the necessary documentation
so that you may submit your own medical claim to your insurance for partial reimbursement. If you seek
coverage and/or reimbursement through your health insurance, you also agree to assume full financial
responsibility for any owed fees not paid by your insurance company.
Northwest Family Life Affiliation
I am an affiliate of Northwest Family Life (NWFL), a group practice in Seattle, WA. As part of my
affiliation with NWFL, I am an in-network preferred provider with Premera. If you opt to use Premera as
payment for your sessions, I will request that you provide me with a Release of Information to both
NWFL and your insurance carrier in order to utilize your coverage.
Cancellations and Missed Appointments
Since regularly attending appointments is essential for effective therapy, I emphasize the importance of
keeping all scheduled sessions. If for some reason you are unable to keep a scheduled appointment,
please provide me with 24-hour notice. If less than 24-hour notice is provided, you will be charged a
$60.00 late cancelation fee. I will consider waiving this fee if you are sick or an emergency has occurred.
If you do not attend an appointment and provide no notice to me, you will be charged the full session
fee. It is not possible to bill insurance for a missed appointment.
Clinician Disclosure; Molly Simkins Sluk, M.A., LMFT / 2
Contacting Me by Phone
If you need to check in, discuss, bring up, or clarify any issues over the phone between sessions, please
feel free to do so. You can call my confidential voicemail to leave a message. I return phone calls within
24-48 hours. For phone consultations that exceed 15 minutes, you will be responsible for a fee of $30.00
for each 15-minute increment used. If you need additional support beyond a phone conversation, please
schedule a face-to-face therapy session with me. In addition, should an urgent matter arise between
your scheduled appointments, please do not hesitate to call me. In the case of an emergency, please
follow the emergency procedures listed below.
Emergencies
I do not offer after-hours crisis support. In the event that you are in crisis, please call either 911 or the
Crisis Clinic at 206-462-3222 or 866-427-4747.
E-mail and Text Message Communication
I do not use an encrypted email for my primary email system. Please refer to the Use of Email and
Texting Informed Consent for additional information regarding the risks associated with using email and
text message communication to send protected health information. If you choose to email or text
message me, please keep the content general. I will be able to respond in a similar way, pending your
choices indicated on the Informed Consent. I will protect your electronic/digital information to the best
of my ability using password security.
Termination
It is your right to discontinue counseling at any time. When possible, please allow one to three sessions
to address therapy closure. I recommend people conclude therapy once they have reached their goals
and can maintain their progress without therapy services. In certain circumstances, I may determine
that I will need to refer you to another provider because your treatment need may not fall within the
scope of my practice. If this be the case, I will provide a referral.
Confidentiality
You have the right to confidentiality under the conditions specified in my Notice of Privacy Practices. If I
see you together with your partner or with other family members, confidentiality extends to all those
involved in the therapy and I will not release to third parties any information without first obtaining
signed releases from everyone involved. In the state of Washington, this includes children age 13 years
and older. However, I will not necessarily be bound by confidentiality in joint sessions with information I
have obtained in individual sessions or discussions. This means I reserve the right to discuss in joint
sessions information that you have shared in individual sessions or discussions if I believe it helps
facilitate the achievement of the goals set forth in therapy.
Client Rights
You have the right to refuse treatment at any time. You also have the right to choose a treatment
provider and treatment modality which best suits your needs. You have the right to raise questions
about my therapeutic approach and to request a referral if you believe you might make better progress
with another therapist. If you prefer that I do not document your sessions with case notes, you can
make this request in writing. Additional rights regarding your Protected Health Information are specified
in my Notice of Privacy Practices.
Clinician Disclosure; Molly Simkins Sluk, M.A., LMFT / 3
Unprofessional Conduct
If you believe I have engaged in unethical or unprofessional conduct, you also have the right to report
your concerns to the Department of Health. You are welcome to contact the Department of Health in
order to obtain a list of the acts of unprofessional conduct listed under RCW 18.130.180. This RCW is in
place to provide protection for public health and safety and to empower you by providing a complaint
process against those counselors who would commit acts of unprofessional conduct.
Department of Health: Complaint Intake
P.O. Box 47857, Olympia, WA 98504-7857
Phone: (360) 236-4700 / Fax: (360) 236-2626 / Email: [email protected]
Your Payment Plan
Cost per Session: _______________________________________________________________________
Acknowledgement of Disclosure
I(we) understand the information and agree to the terms set forth in the above disclosure statement.
I(we) have had the opportunity to ask questions. I(we) am(are) aware of my(our) right to stop
counseling at any time. I(we) am(are) aware of my(our) right to confidentiality and the exceptions. I(we)
have been provided with a copy of this form. I(we) have received a copy of the Notice of Privacy
Practices and had an opportunity to ask questions. I(we) have also been informed of my(our) client
rights in accordance with state and federal laws.
____________________________________ ______________________________
Signature
Printed Name
_____________
Date
____________________________________ ______________________________
Signature
Printed Name
_____________
Date
____________________________________ Molly Simkins Sluk, M.A., LMFT
Therapist’s Signature
Printed Name
_____________
Date
Clinician Disclosure; Molly Simkins Sluk, M.A., LMFT / 4
NOTICE OF PRIVACY PRACTICES
Molly Simkins Sluk, M.A., LMFT
This Notice describes how healthcare information about you may be used and
disclosed and how you can get access to this information.
Please read this Notice carefully.
The Health Insurance Portability and Accountability Act (HIPAA) mandates the protection and
confidential handling of protected healthcare information. This Notice informs you of your rights
regarding your healthcare information under HIPAA. Your health information includes any information
that I record or receive about your past, present, and future healthcare. HIPAA regulations require that I
maintain this privacy and provide you a copy of this Notice.
RECORD KEEPING PRACTICES
Standard practice requires me to keep a record of your treatment. This includes relevant data about
dates of service, payments for service, insurance billing, and relevant treatment information. This record
of treatment is you protected health care information or “PHI”. I may use or disclose your PHI for
treatment, payment, and healthcare operation purposes.
USES AND DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS
TREATMENT. I may use or disclose your PHI to coordinate or manage your treatment. An example of
treatment would be when I consult with another healthcare provider or therapist.
PAYMENT. I will disclose your health care information if you require that I bill a third party. An example
of payment is when I disclose your PHI to your health insurer to obtain reimbursement or to determine
eligibility or coverage.
HEALTHCARE OPERATIONS. I may disclose your PHI during activities that relate to the performance and
operation of my practice. Examples of healthcare operations are quality assessment activities, case
management, legal, audits, and administrative services.
USES AND DISCLOSURES THAT DO NOT REQUIRE YOUR
AUTHORIZATION OR AN OPPORTUNITY TO OBJECT
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. Examples
are public health reports, law enforcement reports, abuse and neglect reports, and reports to coroners
and medical examiners in connection with death. I also must make disclosures to the Secretary of the
Department of Health and Human Services for the purpose of investigating or determining my
compliance with the requirements of the Privacy Rule.
HEALTH OVERSIGHT. I may disclose your healthcare information to a health oversight agency for
activities authorized by law, such as my professional licensure. Oversight agencies also include
government agencies and organizations that provide financial assistance to me, such as third party
payers.
Notice of Privacy Practices / 1
CHILD ABUSE OR NEGLECT. If I have reasonable cause to believe that a child (under the age of 18 years)
has suffered abuse or neglect, I am required by law to report it to the proper authorities.
ADULT ABUSE. If I have reasonable cause to believe that abandonment, sexual or physical abuse,
financial exploitation, or neglect of a vulnerable adult has occurred, I must report the abuse to the
proper authorities.
THREAT TO HEALTH OR SAFETY. I may disclose your PHI for purposes of safety if I have good reason to
believe that disclosure will avoid or minimize an imminent danger to the health or safety of you or
another individual, although there is no obligation on my part to disclose.
IN RESPONSE TO CHARGES AGAINST ME. I will be required to disclose your PHI if you wave the
privileges by bringing charges against me.
CRIMINAL ACTIVITY. I may disclose your healthcare information to law enforcement officials if you have
committed a crime on my premises or against me.
BUSINESS ASSOCIATES. I may disclose your healthcare information with business associates that I
contract with to administer billing and/or legal services. My contract with them requires them to
safeguard the privacy of your information.
COMPULSORY PROCESS. I may be required to disclose your PHI if a court of competent jurisdiction
issues an appropriate order. I will comply with this order if (a) you and I have each been notified in
writing at least fourteen days in advance of the subpoena or other legal demand, (b) no protective order
has been obtained, and (c) I have satisfactory assurances that you have received notice of an
opportunity to have limited or quashed the discovery demand.
USES AND DISCLOSURES OF HEALTHCARE INFORMAITON WITH YOUR WRITTEN AUTHORIZATION
I will make other uses and disclosures of your PHI only when your appropriate authorization is obtained.
An “authorization” is written permission that permits specific disclosures. You may revoke this
authorization in writing at any time, unless I have taken an action in reliance on the authorization of the
use or disclosure you permitted, such as providing you with healthcare services for which I must submit
subsequent claims for payment.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
1. You have the right to inspect and copy your PHI, which may be restricted in certain limited
circumstances, for as long as I maintain it. I will charge you a reasonable cost-based fee for
copies.
2. You have the right to ask that I amend your record if you feel that the PHI is incorrect or
incomplete. I am not required to amend it, however you have the right to file a statement of
disagreement with me, to which I am allowed to prepare a rebuttal and it will all go into your
record.
3. You have the right to request the required accounting of disclosures that I make regarding your
PHI. This documents any non-routine disclosures made for purposes other than your treatment,
as well as disclosures made pertaining to your treatment for purposes of quality of care.
Notice of Privacy Practices / 2
4. You have the right to request a restriction or limitation on the use of your PHI for treatment,
payment, or operations of my practice. I am not required to agree to your request, and in
instances where I believe it is in the best interest of quality care I may not honor your request.
5. You have the right to request confidential communication with me. An example of this might be
to send your mail to another address or not call you at home. I will accommodate reasonable
requests and will not ask why you are making the request.
6. You have a right to have a paper copy of this Notice.
7. If you believe I have violated your privacy rights you have the right to file a complaint in writing
with me and/or the Secretary of Health and Human Services. I will not retaliate against you for
filing a complaint.
THERAPIST’S DUTIES
This Notice describes your rights regarding how you may gain access to and control your PHI and how I
may use and disclose it. I am required by law to abide by the terms of this Notice of Privacy Practices and
reserve the right to change the terms of this Notice at any time. Any new Notice of Privacy Practices will
be effective for all PHI that I maintain, whether or not you are still in treatment with me. You may
request a copy of my revised Notice of Privacy Practices at your appointment time, or by leaving a
request on my voicemail to receive a copy through the mail. My revised Notice of Privacy Practices will
be available in my office.
CONTACT INFORMATION
I am my own Privacy Officer. If you have any questions about this Notice, please contact me. My contact
information is: Molly Simkins Sluk, M.A., LMFT
Phone: (206) 790-2364
Email: [email protected]
COMPLAINTS
If you believe I have violated your privacy rights, you may file a complaint in writing to me. I will not
retaliate against you for filing such a complaint. You may also file a complaint with the U.S. Secretary of
Health and Human Services.
Signature below is only acknowledgement that you have received this Notice of Privacy Practices and
had the opportunity to ask any questions about it.
____________________________________ ______________________________
Signature
Printed Name
_____________
Date
____________________________________ ______________________________
Signature
Printed Name
_____________
Date
____________________________________ Molly Simkins Sluk, M.A., LMFT
Therapist’s Signature
Printed Name
_____________
Date
Notice of Privacy Practices / 3
Molly Simkins Sluk, M.A., LMFT
Licensed Marriage and Family Therapist. License Number: LF60402154
3400 Harbor Ave SW, Ste. #203, Seattle, WA 98126
Phone: (206) 790-2364; Fax: (888) 972-7936
Use of Email and Texting Informed Consent
I do not use an encrypted email for my primary email system. Please be aware that email and texting
communication can be intercepted in transmission or misdirected. There is a risk associated with your
use of email and text messaging to communicate protected health information. Please consider
communicating any sensitive information by telephone or in person. Please let me know if you prefer not
to use email or text message communication. Also, it is possible to utilize an encrypted email system and
secure texting apps for Smart phones. Please let me know if you would like to discuss these options.
Finally, please be aware of the risks associated with using your work email or phone to communicate
sensitive information. It may be possible for your employer to have access to information exchanged
through your work email or phone.
Consent
I have received Molly Simkins Sluk’s Use of Email and Texting Informed Consent and had an opportunity
to ask questions. I am aware of my right to choose whether I want to communicate with Molly Simkins
Sluk by email or text messaging. I am aware of my right to request use of an encrypted email system or
secure texting app and will set this up if I choose this option. I have been provided with a copy of this
form and discussed the risks associated with using a work email or phone and I indicated the preferred
email address and phone number for communication with Molly Simkins Sluk.
⃝ I prefer to not use email communication with Molly Simkins Sluk.
⃝ I prefer to not use text messaging communication with Molly Simkins Sluk.
Preferred phone number: ________________________________________________________________
Preferred email (if choosing to communicate by email): ________________________________________
____________________________________ ______________________________
Signature
Printed Name
_____________
Date
____________________________________ ______________________________
Signature
Printed Name
_____________
Date
____________________________________ Molly Simkins Sluk, M.A., LMFT
Therapist’s Signature
Printed Name
_____________
Date
Use of Email and Texting Informed Consent / 1
Molly Simkins Sluk, M.A., LMFT
Licensed Marriage and Family Therapist. License Number: LF60402154
3400 Harbor Ave SW, Ste. #203, Seattle, WA 98126
Phone: (206) 790-2364; Fax: (888) 972-7936
Minimum Record Keeping Agreement
I do not believe that keeping detailed records of what happens in each session is either clinically or
practically useful. Therefore, I will only keep written records of session content when it is legally or
ethically appropriate.
Such circumstances will include documentation of at-risk behaviors (either to self or others);
documentation of information related to suspected child/vulnerable adult abuse or neglect; when
required by legal authorities due to the client being in court mandated treatment (under state or federal
laws); or if documentation of certain issues or events is deemed clinically useful as a way to track crucial
details of the therapeutic process (as in for use in consultation/supervision in order to provide the best
service to the client).
I will abide by all other state requirements (WAC 246-810-035) for record keeping which requires me to
keep, at the very least: the client name; fee arrangement and record of payment; dates of services
received, signed disclosure form, and this record of an agreement to not keep other session records.
_____ I agree to this statement to not keep session records.
_____ I ask that records be kept of all sessions.
____________________________________ ______________________________
Signature
Printed Name
_____________
Date
____________________________________ ______________________________
Signature
Printed Name
_____________
Date
____________________________________ Molly Simkins Sluk, M.A., LMFT
Therapist’s Signature
Printed Name
_____________
Date
Minimum Record Keeping Agreement / 1
Molly Simkins Sluk, M.A., LMFT
Licensed Marriage and Family Therapist. License Number: LF60402154
3400 Harbor Ave SW, Ste. #203, Seattle, WA 98126
Phone: (206) 790-2364; Fax: (888) 972-7936
New Client Registration
Today’s Date: ___________________
Client Identification and Contact Information [For couples/families, each individual should complete this form.]
Your Name and Age: __________________________________ Date of Birth: _____________________
Home Address: _______________________________________________________________________
City: ________________________________
State: _________ Zip code: ______________________
Cell Phone: ___________________________________ Okay to leave message? Yes____ No____
Home Phone: _________________________________ Okay to leave message? Yes____ No____
Email Address (if choosing to use email correspondence): _____________________________________
How can I best contact you? _____________________________________________________________
Employer: _____________________________________ Occupation: ____________________________
Emergency Contact: Name: _______________________ Relation: ___________ Phone: _____________
What brings you to counseling? __________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Previous counseling experience? _________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Medical Care
Are you currently under medical care? Yes____ No_____
If yes, then please describe_______________________________________________________________
_____________________________________________________________________________________
Clinic and Doctor’s Name:__________________________________________ Tel #:_________________
Known Allergies:_______________________________________________________________________
Known medical problems or current medications:_____________________________________________
_____________________________________________________________________________________
Relationship Information [Please complete the portions of this section relevant to your situation.]
If in a primary relationship, name of partner:_________________________________________________
How long have you been together?_____ If living together, how long?_____ If married, how long?_____
Do you have any children? If yes, please indicate the following:
_________________________________ ________________ ____________ _________________
Name
Gender
Age
Name
Gender
Age
Name
Gender
Age
Living with you? y/n
Name
Gender
Age
Living with you? y/n
_________________________________
_________________________________
_________________________________
________________
________________
________________
____________
____________
____________
Living with you? y/n
_________________
Living with you? y/n
_________________
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New Client Registration / 1