DISCLOSURE STATEMENT
| Dana Kovalchick, MA, LMHC Therapist for Individuals and Couples 2366 Eastlake Ave E, Suite 225, Seattle, WA 98102 206.419.0155 |
Welcome
Participating in therapy can be a rewarding experience for both the client and the therapist. The
following information is presented to make the therapeutic experience more clear and
comprehensive. I hope you will feel comfortable asking questions as you read this document and
if/when questions arise over time.
Therapeutic Orientation and Techniques
As a therapist, I use a variety of techniques to help clients explore their thoughts, feelings, and
behaviors. I see therapy as a team effort in which a therapist and client work together to meet
client objectives. Throughout the course of our work, you, as the client, will be able to teach me
about yourself, and the things you desire for your life. My goal, as a professional, is to unite with
you in a genuine and honest way so that we can work together to navigate the path that you
desire. I will talk with you about what brought you into therapy and what your life has been like
until this point. Together we will support and analyze your life goals.
My therapy often focuses on how life changes can lead to anxiety. Many people come to therapy
to discuss issues of love, loss, isolation, transition, freedom, death, and choice. These topics
require presence and understanding so that we can look at your options, barriers, and worries.
During change, decisions are important yet difficult. We will talk about how personal choice
impacts your direction in life.
On occasion, I also practice a specialized therapy that educates people on how to focus their
minds, regulate their emotions, tolerate distress, and be more interpersonally effective with
others. This can be done in groups or on an individual basis.
Most importantly, my belief is that our relationship as client and therapist is the strongest part of
therapy. I will work to create a comfortable and safe place for you to share your life, and I hope
you will help me to determine what works best for you as a client. Your feedback is important. If,
at any point, you have concerns or issues with the relationship we are building, please talk with
me. As a client, you have the right and responsibility to determine if you would like to refuse or
discontinue therapy. I will be happy to refer you to another therapist if you feel that a different
approach would fit you better.
Education and Training
In 1996, I received my Bachelor’s degree in Psychology from Brown University in Providence,
Rhode Island. In 2003, I received my Master’s degree in Mental Health Counseling from Seattle
University in Seattle, Washington.
During and after my undergraduate and graduate training, I assisted research on sleep, panic
response to emergencies, mental health advance directives, and self-harm. Clinically, I have
worked with all ages in individual, couples, group, and family settings. I interned at Seattle
Children’s Outpatient Psychiatry, and following my master’s program, acted as a community mental
health counselor at Southeast Youth and Family Services. As a volunteer, I have tutored,
mentored, been a big sister, assisted literacy, and answered calls at a 24-hour suicide hotline.
I am an expert speaker on adjustment to parenthood, postpartum mood disorders, and enhancing
the couple’s relationship for the Program for Early Parent Support (PEPS) organization. I have
also served as adjunct faculty at Seattle University where I supervised and taught master’s level
students in the mental health counseling program. I regularly attend trainings and workshops to
advance my skills and competency. I am a licensed mental heath counselor (LMHC#
LH00010788) in Washington State.
Fees, Insurance, and Office Policies
The fee for individual counseling is $100 per 50 minute session. Couples and family counseling is
$120 per 50 minute session. I have limited availability for sliding fee clients. From time to time, my
fee may increase. If payment becomes a hardship, let me know, and we will discuss options.
Payments are due at the time of the session. Cancellation less than 24 hours in advance will
result in full payment due for the missed session. I am available to consult with doctors,
prescribers, and other professionals for a fee. If you would like me to contact one of your
providers, we will sign the appropriate release of information, and I will charge $100 per hour for
preparation and consultation. If you are interested in reimbursement through insurance, I can
provide you with a receipt reflecting paid sessions. I choose not to directly correspond with or
submit to insurance companies.
Consultation and Supervision
I regularly participate in consultation and supervision with other mental health professionals. This
allows me to stay current in my practice and to gain other perspectives on my cases. During
consultation and supervision, I take every effort to maintain confidentiality so that I do not reveal
identifying information.
Confidentiality
As a client, you have the right to confidentiality. As a professional, I will strive to protect the
information that you share with me; however, there are certain limitations to confidentiality. These
limitations are more complicated when it comes to therapy with couples, families, or groups. The
following are exceptions to confidentially (according to RCW 18.225.105):
1. If the client gives written authorization (release of information).
2. If the client waives privileges by suggesting a crime against another person.
3. If there is a subpoena or court order for records (under RCW 18.130.050).
4. If there is suspected abuse or neglect of a child or elder or if there is suspected intent to harm
oneself or somebody else.
5. If I believe that informing an individual will avoid or minimize imminent danger or harm to health
and/or safety (duty to warn).
6. If a client is under the age of 13.
State Contact Information
If you suspect that my conduct has been unprofessional in any way, please discuss this issue with
me. As a consumer, you can also contact the State Department of Health to request a copy of the
law relating to counselors. Health Professions Quality Assurance, Consumer Service Center, PO
Box 47865, Olympia, WA 98504, 360.236.4700.
Contacting Me
If you need to reach me to schedule or change an appointment, you may leave a message for me
at 206.419.0155.
Emergencies
If you are in crisis or have an emergency, please call 911 or the 24-hour Crisis Clinic at
206.461.3222 or 866.427.4747 (866.4CRISIS). Teens, please call the Crisis Clinic Teen Link at
206.461.4922 or 866.TEENLINK.
Agreement for Therapy
Please sign below that you have read this disclosure and have asked any questions about the
information provided. Signature also acknowledges that you have received a copy of the “Notice
of Privacy Practices” handout.
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Client Signature Date
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Client Signature Date
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Therapist Signature Date
