Therapist Disclosure Statement

    Education and Training
    I trained as a mental health counselor at the School of Applied Psychology, Counseling and Family Therapy at Antioch University Seattle, where I earned an MA degree. I completed an internship at Sound Mental Health working with chronically mentally ill adults. I hold a BA from Barnard College, Columbia University, and an MHL (Master of Heb. Letters) From Gratz College. In accordance with WA State law (WAC 308­109­040), I am a Licensed Mental Health Counselor (LH-60288715).

    I am a member of the American Counseling Association; the Association for Positive Discipline; the International Association of Marriage and Family Counselors; Seattle Counselors Association; and the Puget Sound Adlerian Society.

    Therapeutic Approach
    My approach, drawing from several theoretical orientations, is client-centered, based on the belief that every individual brings a unique and formative personal, family and cultural experience. I have been influenced by Adlerian Individual Psychology, with its emphasis on the healing power of the therapist- client relationship.

    In our sessions, we will explore the places you feel stuck, unresolved issues and unhealed emotional wounds that may be keeping you from moving forward or are causing you distress. We will look at the way your family/cultural history has impacted your current values, relationships, and behaviors. We will examine thoughts, feelings and beliefs that influence your choices and your reactions to situations in which you find yourself today. During the therapeutic process, it is important you let me know if anything makes you feel uncomfortable or uneasy. You may ask questions about anything that happens in therapy or request a change in direction.

    Counseling is most effective if carried out on a regularly scheduled basis, and with adherence to strict boundaries of time and space. Therapy sessions are scheduled for 50 minutes, unless a longer time is negotiated. Couples/family sessions may be scheduled for 75 minutes. Sessions start and end exactly at the scheduled time.

    If you are late for an appointment, you will have the remainder of the scheduled hour available to you; we will not run over the scheduled time. If I begin a session late, I will either see you for a full 50 minutes, charge you a pro­rated fee, or schedule a subsequent, and proportionately longer, session. If you need to cancel an appointment, please do so 24 hours in advance to avoid being charged. If you miss an appointment due to unusual circumstances, feel free to discuss this with me. Should I ever miss an appointment without prior notification, I will see you at your next appointment free of charge.

    I travel approximately 2-3 times a year for periods of 1-4 weeks. I will let you know at least a month in advance of my departure. I will also leave you the name of a respected mental health counselor you can contact in case of emergency while I am away.

    My fee is $100 for a 50-minute session, and $150 for a 75-minute session.

    The reduced-rate package is billed at $535 for six 50-minute sessions, payable at the first session and non-refundable. Efforts will be made by both Simcha and the couple to schedule the sessions over the course of 6 consecutive weeks; all pre-paid sessions in each engagement must be scheduled within a 3‐month time frame.

    Payment is due at the end of each session. If you need to make a different arrangement, please let me know and we will discuss it. I do not accept insurance at this time, although some clients may be able to seek full or partial reimbursement from companies by submitting a receipt. As a general rule, if a client is behind in payment for two sessions, I will place our meetings on hold until the client has caught up with payments.

    I tend not to be available for contact on evenings and weekends. During business hours, I will return your phone calls within a few hours. If you are in crisis and need more immediate attention and I am not available, please call the Crisis Clinic number at: (206) 461-3222.

    If you believe that you cannot keep yourself safe, please call 911, or go to the nearest hospital emergency room for assistance. If I must be away for an extended period, I will leave the name and phone number of a therapist who will be covering my practice during my absence.

    Although the client is generally the one who decides when to end therapy, I also reserve the right to do so, allowing at least one session for closure. If, however, the client verbally or physically threatens or harasses my family or me, I reserve the right to terminate treatment immediately and unilaterally. Although I will offer that client referrals to other sources of care, I cannot guarantee acceptance for therapy.

    Ending a therapeutic relationship is best done in person, rather than over the phone. I recommend at least one, and up to three, sessions to properly bring your therapy to a close. You have the right to discontinue therapy at any time.

    Client Consent to Counseling
    I have carefully read and understand this statement. I understand the limits to confidentiality required by law. I understand my rights and responsibilities as a client, and my therapist's responsibilities to me. I agree to undertake therapy with Simcha Shtull. I may end therapy at any time and refuse any requests or suggestions made by Ms. Shtull.

    I have been provided with a copy of this form. I have had the opportunity to ask questions and have received needed clarification.

    Client (1) name:

    Client (1) email:

    Client (2) name:

    Client (2) email:


    I/we agree to pay the following fee per session:

    By clicking the "Yes" box, I/we attest that I/we have read the above Disclosure Statement, and agree to enter into a therapeutic relationship with Simcha Shtull.