HIPAA Statement

    As a client receiving counseling services in the State of Washington, you have the right to:

    • Choose the counselor and treatment approach that best suits your needs and purposes;
    • Have full and complete knowledge of your counselor’s qualifications and training;
    • Be fully informed as to the terms under which services will be provided; and
    • Refuse treatment.

    Our sessions are held in the strictest confidence; no information about you may be released without your written permission or by court order. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law insures the confidentiality of all electronic transmission of information about you; whenever I transmit information about you electronically (for example, sending bills or faxing information), it will be done with special safeguards to insure confidentiality.

    Under the provisions of the Health Care Information Act of 1992, I may legally speak to another health care provider about you, without prior consent. I meet regularly with a supervisor in order to gain a better understanding of how to work most effectively with my clients.

    If you elect to communicate with me by email at some point in our work together, please be aware that email is not completely confidential, as the Internet service provider’s system administrator(s) might, in theory, read these emails.

    State law requires the following exceptions to confidentiality:

    • If the counselor has good reason to believe that the client will harm another person;
    • If the counselor has a reasonable suspicion that a person under the age of 18, or a dependent adult (aged, or developmentally delayed) is or has been physically abused, sexually abused, or neglected;
    • If the counselor has good reason to believe the client is in imminent danger of harming himself, s/he may legally break confidentiality and call the police or the county crisis team;
    • If the client informs the counselor of another named health or mental health care provider who has either engaged in sexual contact with a client or is impaired from practice due to cognitive, emotional, behavioral, or health problems, the law requires the counselor to submit a report to the WA Department of Health’s licensing board.

    Confidentiality in Couples Counseling
    If you and your partner decide to have some individual sessions as part of couples therapy, what you say in those individual sessions will be considered part of the couples therapy, and can and probably will be discussed in our joint sessions. I will remind you of this policy before beginning such individual sessions.

    Record Keeping
    I keep brief notes of our sessions. If you prefer that I keep no records, you must provide me with a written request to this effect, and I will note only your attendance in your record. Under the provisions of the Health Care Information Act of 1992, you may request that a copy of your file be made available to another health care provider. I will not disclose your record to others unless you direct me to do so, or unless the law authorizes or compels me to do so.

    By law I am required to keep records of our sessions for 5 years unless you request in writing that no records be kept beyond basic identification. I maintain your records in a secure location.

    If you are unhappy with what's happening in therapy, please share this with me so that I can respond to your concerns. If you believe I have behaved in an unprofessional or unethical manner, please advise me so that the problem can be clarified and resolved. If discussion proves ineffective, you may contact:
    Department of Health Counselors Program
    PO Box 47869
    Olympia, WA 98504­7869
    Tel: (360) 236­4902

    Client Consent to Counseling provided by Simcha Shtull, LH-60288715

    I have received and reviewed the HIPAA Disclosure – Notice of Privacy Practices. I have had the opportunity to ask any questions regarding this material and understand the information provided. I am of sound mind and body, participate voluntarily, and understand that I am personally responsible for my experience.

    Client Signature

    Client (1) name:

    Client (1) email:

    Client (2) name:

    Client (2) email:


    By clicking the "Yes" box, I/we attest that I/we have read and understand the contents of this HIPAA Statement.