As a new client to my counseling practice I would like to invite you to please read and make a copy of my disclosure statement, fill out the requested information and sign the last two pages. Please bring this with you when you come to my counseling center for your first visit. Also please read the attached HIPPA Notice of Privacy Statement.

This notice describes how medical information about you may be used and disclosed in a  counseling center, and how you can get access to this information. This information will include the Protected Health Information (PHI), as that term is defined in privacy regulations issued by the United States Department of Health and Human Services pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and, as applicable, RCW Chapter 70.02 entitled “Medical records-- Heath Care Access and Disclosure.” Please review it carefully. I understand that your personal health information is very sensitive. I will not disclose your information to others unless you tell me to do so, or unless the law authorizes or requires me to do so.