Re-Source Counseling Center, PLLC Information
- Jules (Juli) Steffen, MA, Ed.S., LMHC, CHT, PPN
- Graduate Degrees: Master of Arts with emphasis in School Psychology; Specialist in Educational Psychology
- Washington State Licensure: Licensed Mental Health Counselor
- Professional Certifications: Advanced Clinical Hypnotherapist; Certified Release Therapist; Prenatal and Perinatal Educator
- Retired status: Nationally Certified School Psychologist (State of Indiana)
- Employer: Re-Source Counseling Center, PLLC Sequim RCC
- Mailing Address for Jules Steffen: P.O. Box 300, Sequim, WA 98382
- Website: www.julessteffen.com
- Email Address: julessteffen@re-sourcecounseling.com
- Jules’ Cell: 206-473-7178
- Re-Source Counseling Center, PLLC:
- RCC Eastside Physical Address: 10532 NE 68th Street, D-101, Kirkland, WA 98003-7002
- RCC Mailing Address: P.O. 1074, Twisp, WA 98856 (for all payment transactions for Jules’ services)
- RCC Email Address for Sue Koptonak (for all payment questions): skoptonak@re-sourcecounseling.com
- Sue Koptonak, Billing Staff (in RCC Office on Tuesdays only): 206-919-1230
- RCC Office: 206-909-6434 (Not a contact # for Jules)
Greetings and welcome to my practice. This Disclosure Statement/Informed Consent is to introduce myself, offer information to help you decide whether you believe we can work together, and provide clarity regarding specific issues for the duration of psychotherapeutic care. When you sign this six-page document, it will represent an agreement between us. You have the right to choose a health care provider who best suits your needs and purposes, and you have the right to refuse/terminate treatment. With this in mind, please read carefully the following disclosure information for counseling services and let me know if you have any questions. You will also find this Health Provider Disclosure Statement/Informed Consent on my website at https://julessteffen.com.
Credentials
I am a Licensed Mental Health Counselor in the State of Washington. My license number is LH – 00011310. I received my Master of Arts degree in School Psychology in 1984 and my Specialist in Education degree (with emphasis in School Psychology) in 1986, both from Ball State University in Muncie, Indiana. My School Psychologist Indiana License with the Department of Education: 1) Standard License: 1987; 2) Professionalized Life License: 1990. I am no longer utilizing my School Psychologist License.
My training is primarily in cognitive-behavioral, hypnotherapy, and specialized study in pre- and perinatal psychology, targeting the impacts of shock during the prenatal and perinatal periods.
I am a Pre- and Perinatal Educator (PPN), trained by Emerson Seminars. My certificates from Emerson Seminars are 1) Level 1 Training Program in Pre- and Perinatal Psychology in 2006; 2) Modules 1- VI of the Clinical Baby Training in 2010; 3) ongoing pre- and perinatal course work.
My certifications include: Certified Release Therapist, Clinical Hypnotherapist, and Advanced Clinical Hypnotherapist (1997/1998) from The Wellness Institute. I have retired status as a Nationally Certified School Psychologist (NCSP).
I am a member of the American Mental Health Counselors Association and the Washington Mental Health Counselors Association.
Counseling Approach
First and foremost, you are responsible for choosing your provider(s) of psychotherapeutic services as well as negotiating and choosing the treatment modality that best suits your needs. With regard to our psychotherapeutic relationship, you understand that the course of treatment will be negotiated and refined by you and me throughout the duration of treatment. You also understand that you can refuse/terminate treatment at any time.
During our first sessions, I will assess if I can be of benefit to you. I do not accept clients who I believe I cannot assist, and should this occur, I will offer you recommendations of other therapists who may be helpful to you. Within a reasonable time period, we will discuss my working understanding of your issues, my proposed treatment plan, therapeutic objectives and potential counseling outcomes. Please ask me if you have specific questions about any counseling techniques utilized during the course of your treatment, their possible risks, my expertise in employing them, or your overall treatment plan. You also have the right to ask about other possible treatments that may be available to you. I will assist you by offering you potential resources such that you may pursue those treatments if you wish.
In counseling, I will be actively involved in working with you, providing information, guidance and support. I offer certain expertise while you bring self-knowledge, reflections from your life experiences, and your perception of what you want in life. The approaches I use may help you change your attitudes and behaviors that cause you emotional pain. We may talk about how you’ve handled difficulties in past 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 our sessions, such as reading a book that I believe may be helpful.
The length of time you are in treatment cannot be known early-on. Counseling is understood to be a choice you’ve made among available options. Other options include: receiving therapy from another counselor, using other therapies, using support groups, seeking self-help resources, and other modes of treatment.
I work from an interactive and integrative perspective and engage various techniques, including:
Cognitive-Behavioral Therapy (CBT): This modality may help you recognize negative patterns of thinking/behavior, evaluate their usefulness, and replace them with healthier thoughts and behaviors that support positive wellbeing.
Hypnotherapy: a sensory experience that supports the simple shifting back and forth between the conscious and sub-conscious mind, a natural process that you frequently experience on your own throughout each day. Hypnotherapy is an empowering process given that all the answers are within you, a process of self discovery as you experience your own inner resources. Your conscious mind analyzes, thinks, plans and uses short term memory. Your sub-conscious mind includes your long-term memory, emotions and feelings, habit patterns, relationship patterns, addictions, involuntary bodily functions, creativity, developmental stages, spiritual connection, and intuition. You are in charge of your hypnotherapy session as you make choices to shift back and forth between your conscious and sub-conscious mind, connecting with your inner resources and integrating positive healing experiences.
Prenatal and Perinatal Psychology: Your prenatal experiences as well as perinatal (just before, during and after birth) are imprinted within you, and may be reflected in the ways you live your life. These early encounters may impact you deeply, and include a diverse collection of experiences, whether it be that of ecstatic joy, positive success, nurturing care, shocking overwhelm, invasiveness, betrayal, abandonment, and many more potential depictions. Potential woundings may limit you in life if you are unaware of their specific impacts. You are in charge of your level of participation for exploring, identifying, and tracking what may be early wounds for you, all-the-while collaborating with me about self-care strategies that appear to be effective for you.
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 many benefits. It often leads to improved interpersonal relationships, can provide solutions to specific problems, and there is often a significant reduction in feelings of emotional distress. Counseling requires your active involvement, honesty and openness in order to change your thoughts, feelings and/or behavior. Your feedback and views of your counseling process and its progress is welcomed.
During the course of counseling, remembering unpleasant events, feelings or thoughts may result in your experiencing discomfort, strong feelings, anxiety, depression, insomnia, etc. I may challenge some of your assumptions or beliefs, or propose different ways of thinking about or dealing with situations that may prompt distress. Attempting to resolve issues that brought you into counseling may result in changes that were not originally intended. Counseling may result in decisions to change behaviors, employment, substance use, education, housing, relationships or other events and experiences that cannot be foreseen. Change may be quick and easy, but more often it is likely gradual and challenging. There is no guarantee that counseling will produce positive or intended outcomes. Having said this, my intention is to support you on your healing journey. Some clients need only a few sessions to achieve their goals, while others may benefit from long-term counseling.
Concerns about Treatment not working, Unprofessional Behavior, Termination, and Follow-up
You have the right and responsibility to choose a provider and treatment modality that best suits your needs. In addition, you have the right to refuse/ terminate treatment at any time. If you choose to do so, I will offer to provide you names of other qualified professionals whose services you might prefer. If you request it and authorize it in writing, I may talk to the therapist of your choice (with your permission only) in order to help with the transition.
If you decide to exercise your right to terminate, it is important to realize that stopping therapy early may result in the return or worsening of the initial problems and symptoms. Deciding when to stop our work together is meant to be a mutual process. Before we stop, we will discuss how you will know if or when to return or whether a regularly-scheduled check-in might work best for you. If it is not possible for you to gradually phase out of therapy, I recommend that we have healthy closure on your therapy process with at least two termination sessions.
If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified.
Noncompliance with treatment recommendations may necessitate early termination of services. I will look at your issues with you and exercise my educated assessment about what treatment will be in your best interest. Your responsibility is to make a good-faith effort to fulfill the treatment recommendations to which you have agreed in session. If you have concerns or reservations about my treatment recommendations, I strongly encourage you to express them so that we can resolve any possible differences or misunderstandings.
If you commit violence to, verbally or physically threaten or harass me, the office, or my family, I reserve the right to terminate your treatment unilaterally and immediately. Failure or refusal to pay for services after a reasonable time is another condition for termination of services. Please contact me to make arrangements any time your financial situation changes.
If during our work together, I assess that I am not effective in helping you reach your therapeutic goals, I am obliged to discuss this with you and, if appropriate, terminate treatment and give you referrals that may be of help to you. If you request it and authorize it in writing, I may talk to the therapist of your choice (with your permission only) in order to help with the transition.
I encourage you to talk with me directly if you are dissatisfied with my services or if you want a second opinion or referral to another counselor. If you intend to discontinue therapy, please discuss it with me first.
If 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
Confidentiality is strictly kept in all aspects of my working relationship with you. There are some exceptions delineated below. In addition to this document, you received my Notice of Privacy Practices, which describes how I might use and disclose your health information. Examples of when I may disclose information about you is: to report suspected abuse of a child, a developmentally disabled person, or a vulnerable adult; when in receipt of information that suggests you or others are an imminent threat to the safety of yourself, others or property (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.
You understand and agree that the limits of confidentiality are compromised by your choice if you use a third party payer such as an insurance company to pay a portion or all of the fees incurred for services. Specifically, “Health Care Information” as defined by “The Healthcare Information Protection and Portability Act of …” includes but is not limited to date of service, time of service, type of service, fee for service, place of service and diagnosis and will be disclosed to your third party payer. More specific and personal information will only be disclosed if requested by your third party payer and you agree to such a disclosure, in consultation with me as your provider, using a separate document outlining the extent of such a disclosure.
Payment by check permits bank employees to view names of my clients given my name may be referenced on the check. All payment transactions are to be made to the Re-Source Counseling Center, PLLC: P.O. Box 1074, Twisp, WA 98856.
Supervision and Consultation
I may utilize supervision or consultation to better serve your case. With this informed consent, you authorize me to retain any such providers necessary in my judgment. Information about you will be described only to the extent necessary. That being said, you understand and agree that the limits of confidentiality do not extend to or include psychological and medical personnel who are associated with me as your provider for the purpose of professional and/or therapeutic consultation or supervision.
Minors
I do not treat minors.
Emails, Phone Calls, Texting and Emergencies
For small administrative matters such as checking/changing appointment times, you are welcome to email me at julessteffen@re-sourcecounseling.com which has enhanced encryption to safeguard your protected health information. Emails are not to be used to discuss substantive clinical matters. I generally return phone calls and emails within 24 hours with the exception of weekends. I cannot safeguard your health protected information when texting; therefore, please limit your texting for the sole purpose of scheduling sessions.
If you need to contact me between sessions about a therapeutic matter, please leave a message for me at 206-473-7178. I check my voice mail messages each day unless I am on vacation. If I am planning on being on vacation, I will let you know in advance. I will also let you know if there is ever an occasion where I have another professional covering for me if I plan not to take or respond to phone messages during my absence. In the event that you are unable to reach me, the phone number for Re-Source Counseling Center, PLLC is 206-909-6434.
You will be charged in quarter-hour increments for telephone calls to me to discuss issues or concerns between sessions. If you feel the need for many phone calls and cannot wait for your next appointment, we may need to schedule more sessions to address your needs. If an emergency situation arises, please indicate it clearly in your message to me. If your situation is an acute emergency and you need to talk to someone right away, contact the closest 24-hour emergency service:
- Dial 911
- Go to your nearest Emergency Room
- National Suicide Prevention Lifeline (800) 273-8255
- Kitsap/Clallam/Jefferson Counties 24-hour Crisis Services (360) 479-3033 or (800) 843-4793
Appointments, Cancellations, Lateness
You understand and agree you are responsible for arranging for your session appointments. You agree to notify me by noon of the prior business day if you choose to cancel. You understand you will provide payment for the unused scheduled time if you do not meet this notice agreement. Missed and cancelled sessions pose some issues for both of us. Counseling is sometimes challenging and when you experience difficult places, it can feel easier to want to avoid your session. I prefer that we speak about this intentionally rather than you canceling sessions. I hold your scheduled appointment time specifically for you and you alone. It is extremely difficult for me to fill your last minute cancelled session on a short notice.
The length of my counseling appointments varies depending on your therapeutic need. My fee is $175 per hour. The minimum time frame for a session is one hour (60 minutes) in length. The initial appointment is 1.5 hours in order to complete the necessary paperwork and begin my assessment of your therapeutic needs. Hypnotherapy sessions are at least 1.5 hours in length, and at times, may extend to 2.0 hours if needed. Since health insurance companies rarely allow payment for more than 60 minutes of therapy per calendar day, you will be charged out-of-pocket for the additional half-hour of services ($87.50) beginning with your initial session, and/or whenever 1.5 hour sessions are used. If additional time beyond 1.5 hours is mutually agreed upon, the out-of-pocket expense will be in accordance with the $175/hour fee.
Payment
Health insurance companies do not pay for missed sessions, nor do they pay for telephone calls, reports, letters, or interactions with attorneys and others; you are solely responsible for payment for these services.
While I do my best to minimize rate changes, from time to time, Re-Source Counseling Center, PLLC may find it necessary to increase the hourly rate. If you are continuing in therapy with me at that time, I will provide you with thirty days advance notice of any such increase. You are not responsible for any costs prior to you being given this notice.
Unless we have made other arrangements, full payment is due at the start of each session. Any co-pay that you may have is due at the start of each session, payable to Re-Source Counseling Center, PLLC. You will be charged in quarter-hour increments for telephone calls to me to discuss issues or concerns between sessions. The same will be true for my telephone interactions with attorneys, physicians, and others on your behalf, and for reports and letters you request me to write on your behalf. You are expected to pay these extra costs at our next session unless specific arrangements are made with me.
You understand and agree that the fee for psychotherapeutic services with me as your provider is $175 per hour, unless other arrangements are made and mutually agreed to. Furthermore, you understand that payment of fees is due at the time of service and can be postponed only with prior arrangements. Any past due balance of fees exceeding 30 days will be subject to a finance charge of 12% per annum or 1% per month.
Legal Proceedings
Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters of a personal and confidential nature, it is agreed that, should there be legal proceedings (such as, but not limited to, divorce, custody disputes, injuries, or lawsuits), neither you (client(s)) nor your attorney(s), nor anyone acting on your behalf will call on me to testify in court or at any other proceedings, nor will a disclosure of the psychotherapy or counseling records be requested. Considering the above exclusions, upon your request, I will release a summary of your sessions to any agency/person you specify, unless releasing the information might be harmful in any way or violates the privacy of another person. If subpoenaed or ordered by an authorized court of law, health care professionals may be required to release confidential information. Time for preparation and/or attendance in court will be charged as permitted by law.
About Insurance
You are responsible for payment of all treatment fees and other costs. If you have health insurance and/or a third party payer, it will usually provide some coverage for mental health treatment. As a courtesy, Re-Source Counseling Center, PLLC will fill out forms and provide you with assistance in helping you receive the benefits to which you may be entitled. It is very important that you find out exactly what mental health services your insurance policy covers and what deductibles and co-pay may apply. Please remember that you are responsible for payment of the full cost of services if your insurance does not cover your services, or if your insurance does not cover the full cost of services beyond the initial 60 minutes that will be billed to insurance.
Your health insurance company and/or a third party payer may require that I provide it with information about your diagnosis, treatment plan, and your attendance at therapy sessions. It is rare, but they may require a copy of your entire treatment record. If you are using insurance and/or third party payer, you acknowledge this and you agree to allow these disclosures.
You understand that many third party payers, like insurance companies, have set limits on the extent of services that they will allow as covered expenses dependent on your policy or contract. These limits may be defined in terms of a maximum number of minutes allowed per session, a maximum number of sessions per day, per week, per month, per year, per illness or per lifetime. These coverage limits could also be specific to your diagnosis or specific to your chosen modality of treatment. You, therefore, understand and agree that if you and me as your provider mutually decide that it is in your best interest to exceed your third parties’ limits of coverage that you will be responsible for payment of these services beyond their limits.
Acknowledgement and Agreement
By signing below, 1) each of us confirms this 6-page disclosure/informed consent document to represent the agreement between us; 2) you confirm receiving and reading a copy, and 3) you confirm your understanding of the information provided and agree to the terms of this document.
________________________________________________________________________________________
Signature of Health Care Provider: Jules (Juli)Steffen/Date
________________________________________________________________________________________
Signature of Client Printed Name of Client / Date
Original – Jules Steffen / Copy – Client Revised by JS 01-01-2019
Portions of this document: 1) 2013 Copyright by Marvin W. Eidinger, Jr. and Robert E. Smith; 2) Frances Schopick, JD, MSW. Permission must be granted before copying any wording from this document.
Jules Steffen, LMHC, CHT, PPN 