Lisa Boyl-Davis, MSW, LICSW
1902 120th PL SE, Suite 102D
Everett, WA 98208
The following information is provided to help you understand the therapy services that I offer. It also informs you of your rights and obligations. You have the right to choose a health care provider who best suits your needs and purposes. With that in mind, please read carefully the following disclosure information for counseling services. You have the right to refuse treatment. Please read it carefully and ask any questions that you may have.
Credentials: I hold a Master of Social Work (MSW) from Walla Walla University of College Place, Washington. I have worked in crisis settings as a psychiatric clinical social worker for 20 years - mostly in the ER, providing intensive interviewing and assessment for patients in crisis, developing a plan that addresses safety, treatment and other needs that arise in the assessment, as well as an appropriate discharge and placement arrangement. Over my years as a social worker I have had the opportunity to work with adults, adolescents, children, families and couples on a variety of challenges. I am an Licensed Independent Clinical Social Worker (LICSW) which allows me to assess, diagnose and treat mental illness and emotional conditions in the State of
Washington #LW 60436232.
I am solo practitioner in private practice working with individuals toward their desire for optimum mental health. My therapy style is eclectic. Every person comes with their own story and unique needs, and a collection of “tools” that have helped them throughout their lives, therefore I offer what I consider to be the most enhancing of what has worked for the individual already, challenge what does not work, and provide support during the change process.
The modalities I ascribe to, and utilize as needed are as follows:
A Client Centered Approach
A Solutions Focus
A Psychoanalytic approach
A Psycho-educational dynamic
Eye Movement Desensitization Reprocessing (EMDR)
Somatic and Creative Therapy approaches
Identifying and supporting the implementation of boundaries
family tree work
for Christians wanting a Christian approach - knowing God as a means of knowing one’s self
…. These are but a few of the many supports I offer
These approaches and techniques may involve assisting you in changing attitudes and behaviors that are causing you emotional pain. We may talk about how you've handled difficulties in recent situations and relationships. Counseling may involve helping you identify, develop, and implement more effective strategies for problem solving and how to make healthier decisions. At times I may ask you to do some specific activities outside of our session, such as practicing skills, reading a book, listening to a CD or watching a movie that I think would be helpful.
The length of time you would be in treatment cannot be known early-on. Some patients need only a few sessions to achieve their goals, while others may benefit from long term counseling. Counseling is understood to be a choice you've made among available options.
The following information is provided to help you understand the therapy services that I offer. It also informs you of your goals and obligations. You have the right to choose a healthcare provider who best suits your needs and purposes. With that in mind, please read carefully the following disclosure information for counseling series. You have the right to refuse treatment. Please read it carefully and ask any questions that you may have.
Risks and Benefits: Counseling can have benefits and risks. Since it often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings, such as sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, counseling has also been shown to have benefits. It often leads to better relationships, it can provide solutions to specific problems, and there is often a significant reduction in feelings of emotional distress.
Concerns about Treatment not working or Unprofessional Behavior
You have the right to terminate counseling at any time. Stopping therapy early may result in the return or worsening of the initial problems or symptoms. I cannot guarantee that the services I offer will help you. At any time, should you feel that your work with me is not useful to you, please bring this to my attention right away. You are, of course, free to accept or reject any of my recommendations. You should question anything I say or recommend with which you disagree, or which you do not fully understand.
I will not be insulted if you request a second opinion about anything that I recommend. On the contrary, the more informed you have the better our work together will go. lf you are concerned about my professional conduct, you may file a complaint with: Department of Health, Health Professions Quality Assurance Division, P.O. Box 47869, Olympia, WA 98504-7869. Their telephone number is (360) 236-4700.
Confidentiality: In addition to this document, you received my Notice of Privacy Practices, which described how I might use and disclose your health information. Examples of when I may disclosure information about you is: To report suspected abuse of a child, a developmentally disabled person, or a vulnerable adult; to interrupt potential suicidal behavior; to intervene against threatened harm to another, which may include knowledge that a patient is HIV positive but a patient is unwilling to inform others with whom he/she is intimately involved; and if required by court order or other compulsory process.
Disclosures may also be made if you sign a written authorization for me to release information to another person or agency, such as your physician. If you file a complaint with the Department of Health, the minimally necessary disclosures will be made to present the Department with the full picture. Payment by check permits bank employees to view names of my patients, because my name will appear on the check.
Minors: If you are a patient under 18 years of age and not emancipated, your parents have the right to examine your treatment records. Since privacy in counseling is often crucial to successful progress, particularly with teenagers, it is common that I request an agreement from the parents that they consent to give up access to their child's records. If they agree, I will provide them only with general information about your progress in treatment, and our attendance at scheduled sessions. Any other communication will require your authorization, unless I feel that you are in danger or are a danger to someone else, in which case I will notify your parents of my concern. Before giving parents any information, I will discuss the matter with you, if possible, and I will do my best to handle any objections you may have.
Billing and Insurance:
The fee for counseling is 125.00 per 50 minute individual session and 200.00 per 90 minute session. Payment in cash or check is made at each session. Please make checks payable to: Lisa Boyl-Davis, LICSW. You will be charged for missed appointments if you have failed to notify me within 24 hours of our scheduled time (illness or emergencies are the exception - which differ from being in a bind such as lacking a babysitter, forgetting, etc..). I do not accept and bill insurance. It is your responsibility to pay the total amount at each session.
I regularly consult with other professionals regarding clients with whom I am working. This allows me to gain other perspectives and ideas for the best way I can help you reach your goals. These consultations are obtained in such a way that confidentially is maintained.
Emergency Services: I am not available for emergency mental health services. My office hours are Monday - Thursday, 9-5. If you are in need of emergency services the 24-hour crisis line is 800-584-3578.
Confidentiality: Your involvement with me is private, confidential, and protected by law. No information about you is released to anyone without your verified, written permission. No one has the right to know you come here, what we talk about, see your records, or discuss your case with me unless you provide written permission. There are three (3) exceptions, which require, by law, release of information without your consent: (1) suspected child or elder abuse, (2) clear evidence of planned or committed acts of violence against self or other and (3) subpoena for information by a court of law. It is occasionally helpful for me to consult about a case with other professionals, and in these case consultations, everyone is legally bound to keep information confidential.
State law requires that the following statement is included:
Acknowledgement and Agreement By signing below, each of us confirms this disclosure document to represent the agreement between us, and you confirm receiving and reading a copy, and you confirm your understanding of the information provided and agree to allow the disclosures of health information as described above.
Signature of Health Care Provider Date
Signature of Patient (or Parent or Legal Guardian) Date
Lisa Boyl-Davis, LICSW
1902 120TH PL SE, SUITE 102D
Everett, WA 98208
Name ________________________________ Date ____________ DOB ____________
Full Mailing Address______________________________________________________
Email: ______________________________________ only if it is ok to communicate by this
Home number _________________________ Can I call you here? ____Can I leave a
message? _____ Cell number ___________________________ Can I call you here? ____
Can I leave a message? _____
Name of emergency contact _____________________ Relationship _______________
Phone number ___________________ Cell emergency number ___________________
Alternative emergency contact _________________________ number _______________________
People who support you Relationship Location
_____________________ _________________ ____________________
_____________________ _________________ ____________________
_____________________ _________________ ____________________
_____________________ _________________ ____________________
When was your last doctor’s appointment? _________________
Please list any past medications and their effectiveness:
Please list any current medications, their effectiveness, and dosage (including herbal):
Please list current medical problems or physical complaints:
Have you ever been hospitalized for physical or mental health issues? If yes, please explain.
Please list any allergies______________________________________________________
How much caffeine(coffee, tea, pop) do you consume in a day? None ___1-2 ___ 3 or more ___
How much sleep do you generally get in a night? Less than 6___ 7-8___ more than 8___
How often do you have a drink containing alcohol? Never__ Monthly or less__ 2 to 4 times a
month__ 2 to 3 a week__ 4 or more times a week__ (Skip questions 2 & 3 if you checked never)
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
1 to 2___ 3 to 4___ 5 to 6___ 7 to 9___ 10 or more__
3. How often do you have five or more drinks on one occasion? Never___ Less than monthly___
Monthly___ Weekly___ Daily___ or almost daily___
Please indicate any of the following struggles that pertain to you:
Intrusive thought Patterns___
Poor body image____
Inability to secure employment____
Conflicts in the workplace____
Please list major life events/illnesses/traumas & the year of each:
What is your goal for therapy or how will your life/heart be when you no longer need
Is there anything you would like me to know? Use the back of this page as needed.
WASHINGTON NOTICE FORM
Notice of Therapists’ Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. I. Uses and Disclosures for Treatment, Payment, and Health Care Operations I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, her are some definitions: “PHI” refers to information in your health record that could identify you.
“Treatment, Payment and Health Care Operations” - Treatment - is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist. - Payment - is when I obtain reimbursement for your health care. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. - Health Care Operations - are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business related matters such as audits and administrative services, and case management and care coordination. “Use” applies only to activities within my [office, clinic, practice group, etc.], such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. “Disclosure” applies to activities outside of my [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures
Requiring Authorization I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. You may revoke all such authorizations (of HI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy. III. Uses and Disclosures with Neither Consent nor Authorization I may use or disclose PHI without your consent or authorization in the following circumstances: Child Abuse: If I have reasonable cause to believe that a child has suffered abuse or neglect, I am required by law to report it to the proper law enforcement agency or the Washington Department of Social and Health Services. Adult and Domestic Abuse: If I have reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, I must immediately report the abuse to the 9 Washington Department of Social and Health Services. If I have reason to suspect that sexual or physical assault has occurred, I must immediately report to the appropriate law enforcement agency and to the Department of Social and Health Services. Health Oversight: if the Department of Social and Health Services subpoenas me as part of its investigations, hearings or proceedings relating to the discipline, issuance or denial of licensure of state licensed mental health counselor, I must comply with its orders. This could include disclosing your relevant mental health information.
Judicial or Administrative Proceedings: if you are involved in a court proceeding and a request is made for information about the professional services that I
have provided to you and the records thereof, such information is privileged under state law, and I will not release information without the written authorization of you or your legal representative, or a subpoena of which you have been properly notified and you have failed to inform me that you are opposing the subpoena, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case. Serious Threat to Health or Safety: I may disclose your confidential mental health information to any person without authorization if I reasonably believe that disclosure will avoid or minimize imminent danger to your health or safety, or the health or safety of any other individual. Workers Compensation: if you file a worker’s compensation claim, with certain exception, I must make available, at any stage of the proceedings, all mental health information in my possession relevant to that particular injury in the opinion of the Washington Department of Labor and Industries, to your employer, your representative, and the Department of Labor and Industries upon request. IV. Patient’s Rights and Therapist’s Duties Patient’s Rights: Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address.) Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process. Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process. Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process. Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically. Therapist’s Duties: I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, I will provide you with a revised copy either during one of our therapy hours or by mail. V. Complaints 10 If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact the Department of Health; Professional Programs Management Division; P.O. Box 9012; Olympia, WA; 985048001. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.