Receipt of Disclosure Statement Form

  • Sound Christian Counseling Inc.


    4800 S. 188th St. Suite 260
    SeaTac, WA 98188
    Ph: 206-762-3007 - Fax: 206-243-9583
  • Dear: Sound Christian Counseling Client,
  • We have recently updated our office policies to include obtaining and holding a credit card authorization on file. We value you as a client and make it a priority to be available for your scheduled appointment.
  • Your authorization allows us to be compensated for the time we have reserved for you when you are unable to keep your appointment. This authorization allows us to charge your credit card for no shows, missed appointments, and cancellation of any scheduled appointments with less than a 24-hour notice. This card may also be used for past due balances unless other arrangements are made.
  • Please fill out the attached form, which will be kept separate from your client file in a locked cabinet and return it to us at your next appointment. Thank you for allowing us to continue to serve you.
  • Veronica Rasmussen, LICSW
  • Sound Christian Counseling, Inc.,
    4800 S. 188th St., Suite 260
    SeaTac, WA 98188
    (206) 762-3007
    www.soundchristiancounseling.com
  • Disclosure Statement and Policies
  • Dear New Client: Thank you for choosing Sound Christian Counseling, Inc. I look forward to working with you. The State of Washington requires that I provide you with certain information to allow you to make an informed decision about participating in counseling.
  • Washington State requires that “counselors practicing counseling for a fee must be licensed with the Department of Health for the protection of the public health and safety. Licensing of the individual with the department does not include a recognition of any practice standards, nor necessarily imply the effectiveness of any treatment:” (WAC 246-810-031)
  • Education: I am a Licensed Independent Clinical Social Worker (LICSW). I earned a B.A. in Psychology from the University of Washington and a Master’s in Social Work, from the University of Texas at Austin. I have over 25 years of experience in the field of social work with 19 of those years spent doing individual and family counseling and prayer ministry with adults, children, and adolescents. Over the last 10 years I have focused working with adults with depression and anxiety. I also enjoy working with couples in the areas of communication, personality and compatibility and personal growth.
  • Treatment Methodology: I use an eclectic approach borrowing from cognitive behavioral therapy, reality therapy and prayer ministry counseling. Incorporated into the counseling process, is my underlying belief in the virgin birth, death, and resurrection of the Lord Jesus Christ. This belief allows me to draw upon and impart faith and hope to those I counsel. I consider myself to be a born-again Christian and my faith background is non-denominational. I incorporate prayer and scripture reading into my sessions when appropriate and encourage clients to develop a personal relationship with Jesus Christ. I also encourage them to develop that relationship through regular Bible reading, prayer, and fellowship with believers.
  • Fees and Payment: My fee is $150 for individuals and $175.00 for couples. Payment is due at the beginning of each session. The fee will be adjusted for longer sessions, and phone calls. All additional services, reports, and evaluations are charged for separately. I accept payment of counseling fees in the form of check, cash, or credit card. I charge $.50 for the use of credit or debit cards
  • Checks are to be made payable to: Sound Christian Counseling, Inc. A $25.00 fee will be charged for NSF (non-sufficient funds) checks. Payment is due at the time of service and we refer all account balances over 45 days past due to collections.
  • Additional Changes:
    1)Please update the Telemental Health Consent Form. I found typos and other errors. I have attached it to the e-mail.
    2) I have added a new blog for December. I have attached it to the e-mail as well.

  • Cancellation of Appointments:

    A twenty-four (24) hour notice of cancellation is required or you will be charged $110.00. You will be given a credit card authorization to complete that will authorize Sound Christian Counseling to charge your credit card for missed or late appointments and unpaid balances. To cancel an appointment you may leave a voice mail message or send an e-mail.
  • Client Rights:
    To choose a counselor that meets your needs.
    To know the method and course of treatment.
    To receive accurate information about the services. To know the cost of services and billing practices. To be informed of confidentiality practices.
    To know the complaint process.
    To terminate services that are not satisfactory.
  • Confidentiality: I will not release information without your written consent. The exceptions to this confidentiality rule are:
    1) If you are at risk of harming yourself;
    2) If you are at risk of harming another person;
    3) If there is evidence of abuse/neglect of a child, disabled, or elderly person;.
    4) If you are involved in litigation and we are ordered by a court to release your records;
    5) In the case of a consultation that the therapist conducts with another licensed therapist about a treatment plan. If your case is the subject of one of these consultations your last name and any unique identifying information will be omitted.
    6) When requested by an insurance company or other third-party payers for whom the client has signed a release or giving access to their treatment information.
  • In a situation where more than one person is present in the sessions, for example; during couples or family therapy, confidentiality becomes limited to the following: Any one of the individuals may seek copies of the records of the couple or family sessions or may release all the records of these sessions to an outside party. When individuals in family or couples therapy are seen apart from the couple or family, these sessions are considered part of the couple or family treatment session and may be discussed during the regular couple or family session.
  • Receipt of Disclosure Statement
  • I hereby certify that I have read, understood and received a copy of the Sound Christian Counseling, Inc. Disclosure statement. I have asked any questions that I have about this statement and agree to the terms described in this document. My signature below indicates that I have received a copy of this agreement.
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