Counselor Disclosure and Consent

James Jackson, MSW, LICSW
Alpine Counseling & Consulting
5209 Pt. Fosdick Drive NW, Suite 205
Gig Harbor, WA 98335

Informed Consent & Disclosure Statement

The following information is provided to help you determine if what I offer as a mental health counselor meets your needs as a client.  I will make time in our first session to review this document and any questions you may have.  This document contains important information about my therapeutic approach, my education, my fees, and your rights as a client including your rights regarding your private health information.  Please read this document carefully and ask any questions that help you fully understand the contents of this disclosure statement and agreement for services.

I am not able to propose an appropriate course of treatment for you until we have spent some time together.  As soon as I am able to identify an appropriate course of treatment, I will discuss it with you.


Your participation in therapy, the content of our sessions, and any information you provide to me during our sessions is protected by legal confidentiality.  Some exceptions to confidentiality are the following situations in which I may choose to, or be required to, disclose this information:

  • If you give me written consent to have the information released to another party;
  • In the case of your death or disability I may disclose information to your personal representative;
  • If you waive confidentiality by bringing legal action against me;
  • In response to a valid subpoena from a court or from the secretary of the Washington State Department of Health for records related to a complaint, report, or investigation;
  • If I reasonably believe that disclosure of confidential information will avoid or minimize an imminent danger to your health or safety or the health or safety of any other person; or
  • If, without prior written agreement, no payment for services has been received after 90 days, the account name and amount may be submitted to a collection agency.

As a mandated reporter, I am required by law to disclose certain confidential information including suspected abuse or neglect of children under RCW 26.44, suspected abuse or neglect of vulnerable adults under RCW 74.34, or as otherwise required in proceedings under RCW 71.05.

If you have any questions regarding your confidentiality, the limits of confidentiality, or the exceptions to confidentiality, please let me know.  I will be happy to discuss this with you further.

For additional information regarding your confidentiality rights, please carefully review the attached HIPAA and Washington State Notice of Rights and Privacy Practices.

Insurance Coverage – Please be advised

As a condition of contracting with most, if not all, insurance companies and other third-party payers, I am required comply with requests for documentation regarding the services I provide to you.  This information typically includes the type of service provided, the dates and times of service, your diagnosis, treatment plan, a description of impairment, progress of therapy, and case notes and summaries.  If you do not want me to provide your confidential information to your insurance company, let me know so that we can discuss alternatives.

Supervision and Consultation

I seek ongoing consultation from colleagues in order to provide you with the best services possible.  I may disclose information about you in consultation with colleagues, in which case I will limit the information I disclose to the minimum amount necessary . 

My Education, Training, and Experience

I am a Licensed Independent Clinical Social Worker regulated by Washington State (Credential Number LW 00004709).

I received a Bachelor of Science degree in Psychology from Arizona State University and a Master of Social Work degree from the University of Washington.  I am a Qualified Geriatric Mental Health Specialist in Washington State.

My thirty-year career in mental health includes clinical and managerial practice in differing settings with many different populations.  These include individual counseling in integrated primary care, individual counseling and intervention in community behavioral health settings, crisis services and acute psychiatric care / treatment, disabled and older adult community case management, intensive psychiatric residential care, and clinical supervision.  I have also held a number of administrative and managerial positions in public and non-profit settings focused on provision of effective mental health services.

Learning is a lifelong endeavor and I strive to stay abreast of developments in evidence-based practices, improve my therapeutic skills and effectiveness.

Therapeutic Philosophy

Every individual has the capacity for recovery from tragedy, unanticipated set-backs, illness, and loss.  Optimal therapeutic results are achieved by an active collaboration between therapist and client.  Each of us has a truly unique history and this requires an individualized and tailored approach to therapy.  As we build trust and establish a therapeutic relationship, I work with clients to identify clear goals that reflect client identified outcomes and optimal performance.  As a social worker, I consider environmental factors that impact my clients including culture, racial and ethnic impacts, community experience, historical and current events.  This is often referred to as a bio-psychosocial approach.

Depending on client needs, our work may involve exploring historical and developmental issues that pertain to present difficulties.

In addition to symptom relief and improved personal satisfaction, I want to teach clients to become their own “therapist” by learning and utilizing tools that can be used for a lifetime.

The therapeutic approach central to my practice is Cognitive Behavioral Therapy (CBT) as conceptualized and applied by Aaron Beck, MD.  Though my therapeutic approach is predominantly CBT, I utilize diverse strategies from recognized theories, disciplines, and evidence-based practices.  These include:  Humanistic / Client Centered Counseling, Gestalt Therapy, Oppression Theory, Psychoanalytic Theories, Problem Solving Therapy, and Motivational Interviewing.

Working with Minors

If you are the parent or guardian of a minor who is seeking treatment, please know that under Washington State law, any child age 13 or older can independently consent to mental health treatment without your permission.  In addition, parents or guardians may not generally access the treatment record of a client aged 13 or older without that client’s written permission.  If you are 13 years of age or older, you have the legal right to seek mental health treatment without obtaining permission from a parent or guardian.

I am not able to provide a recommendation, evaluation, or opinion, in any legal forum relating to separation, divorce, child custody, visitation, or parenting plans.  I will need to be provided with a copy of any parenting plan, custody orders, or any other similar documents, including any changes or revisions made during the course of treatment. Also, it is generally necessary that both parents or legal guardians consent to treatment of their minor child.

Financial Requirements

If I am able to accept health insurance coverage that you have, I agree to abide by the terms and conditions of your insurer.  You remain responsible for any unmet deductible, co-pays, or co-insurance.  It is your responsibility to understand the limitations and extent of your health insurers coverage.  An Intake Session & Diagnostic Assessment (60-90 minutes) is $300. The cost of each 45 minute therapy session is $140 and 60 minute session, $175.00.  Payment is due at the beginning of each session, except as determined by your insurance carrier.

I also provide individual and family consultation where treatment is not the primary focus of sessions, rather professional expertise and advice on mental disorders, treatment, family challenges and dynamics. My rate for professional consultation is $150.00 per hour, also due at the beginning of each session.

I offer professional services for the primary purpose of counseling and psychotherapy, not for the primary purpose of preparing for litigation.  If you are seeking services for preparation of litigation or other legal action, I can help you find a referral to a forensic expert.  I do not normally serve as an expert witness, however, for cases I do chose to participate in, my fee for appearing as an expert witness at trial is $250.00 per hour.

Appointment Cancellation

Health insurance companies do not pay for missed or “no show” appointment fees.  Please remember to cancel or reschedule your appointments more than 24 hours in advance of that session. If you are unable to keep your appointment, you must give me 24 hours advanced notice by leaving a voice message or you will be charged $75 for the session.  Under Washington State Law, you are not liable for any fees or charges for services rendered prior to receipt of this disclosure statement. I offer a limited number of sliding scale appointments based on client financial need.  I will be happy to discuss this if you feel it may apply to your situation.

Telephone Accessibility

If you need to contact me between sessions, please leave a message on my voice mail. I am often not immediately available and try to respond to messages within 24 hours.  I generally do not respond to voicemail on weekends, holidays or when I am out of town.  Please read my Crisis Contact Policy.

Electronic Communications and Social Media Policy

In the regular conduct of my practice, I may make use of a cellular phone, or other portable communication device, to communicate with clients.  In such cases, I will limit the information I store in any portable communication device to the least necessary.  Please be aware that such forms of communication do have inherent risks to client confidentiality.  If you would prefer that I do not store you name and telephone number in a portable communication device, or if you would prefer that I do not communicate with you via cellular phone, please inform me so that we can make alternative arrangements.

In order to best protect your confidentiality, I typically will communicate with clients via email for the purposes of scheduling or canceling appointments only. I cannot guarantee the security or confidentially of information sent via email.  If you need to communicate with me via email for any other purpose, please discuss that with me in person.  I may also employ communications via a HIPAA compliant patient portal, in which case you are responsible for maintaining the privacy of any password you use for access to your records and communications there.

Professional ethics standards do not permit me to communicate with clients via social media. For this reason, I cannot accept any client requests to connect on Facebook, or other similar social media platforms


If, without having made prior arrangements, I have not heard from you in 30 days I will assume that you would like me to terminate our current episode of care and close your active clinical file.  In such cases, we may re-open the file and initiate a new episode of care once we meet in person.


If you are experiencing an emergency or crisis at any time, please call 911 or go to the nearest emergency room.   Alternatively, clients living in Pierce County may call the Pierce County Crisis Line at 800-576-7764.  Clients living in Kitsap County may call or the Crisis Line at (800) 843-4793.  Veterans may want to utilize the Veterans Crisis Line, 800-273-8255.   The National Suicide Prevention Lifeline is 800-273-8255. Consult my crisis policy for additional details.

State of Washington Disclosures

As an individual, you have the right to refuse treatment and the right to choose a practitioner and treatment modality which best suits your needs.  Counselors practicing counseling for a fee must be credentialed or licensed with the Department of Health for the protection of public health and safety.  Credentialing of an individual with the Department of Health does not include a recognition of any practice standards, nor necessarily imply the effectiveness of any treatment. 

A copy of the acts of unprofessional conduct can be found in RCW 18.130.180.  Complaints about unprofessional conduct can be made to:

Health Systems Quality Assurance Complaint Intake
Post Office Box 47857
Olympia, WA 98504-7857
Phone: 360-236-4700

I will provide you with a referral to another counselor if I feel your needs are beyond the scope of my expertise or if you request such a referral.

Consent for Treatment

By signing this document, you are attesting that you have received, read, fully understand and consent to the disclosures, terms, and conditions above, that you have received a copy of your HIPAA and Washington State Notice of Rights and Privacy Practices, have read and fully understand these rights, and have been given the opportunity to ask questions.

By signing this document, you are attesting to your consent to participation in clinical services provided by James Jackson, MSW, LICSW.