ROBERT S. MILLER, LICSW, ACSW, PLLC
275 SE Cabot Drive, Suite B206
Oak Harbor, WA  98277
(360) 632-5267

DISCLOSURE STATEMENT 

This form provides you (the client) with information about my counseling practice, in addition to information provided in the HIPAA Notice of Privacy Practices. 

LICENSURE: I am a Licensed Independent Clinical Social Worker (#LW00005444) in Washington State. 

NATIONAL PROVIDER IDENTIFIERS

ROBERT S. MILLER, LICSW, ACSW, PLLC:  1235369323
Robert S. Miller, Member/Manager:  1477557338

MY EDUCATION & TRAINING

  •  Bachelor of Arts degree in Sociology with honors from Seattle Pacific University (1970)
  • Masters degree in Social Work from the University of Chicago (1972)
  • Diploma in Life Skills Coaching from Stonebridge Associated Colleges (2002)
  • Job Skill Certificate in Supervision and Management, Rutgers University (2007)
  • Job Skill Certificate in Project Management, Rutgers University (2007)
  • Certificate in Aging (geriatric social work), Boston University (2009)
  • Certified Coach in Self-Esteem Elevation for Children (2012)
  • Certificate in Employee Assistance Programs, The Catholic University of America (2013)

I have completed continuing education courses on topics including: 

  • Anxiety
  • Assessing and managing suicide
  • Attachment
  • Attention-Deficit/Hyperacitivity Disorder (ADHD) 
  • Autism Spectrum Disorder
  • Bipolar Disorder 
  • Child and adolescent psychopathology 
  • Cyber-security
  • Depression 
  • Digital ethics
  • EAP services for military personnel and their families
  • Geriatric mental health 
  • Grief
  • Health Insurance Portability and Accountability Act (HIPAA) 
  • In­fant mental health 
  • Internet Addictions
  • Military deployment and reintegration in wartime 
  • Oppositional Defiant Disorder (ODD) 
  • Personally Identifiable Information (PII) and Protected Health Information (PHI)
  • Posttraumatic stress (PTSD) and trauma disorders
  • Principles of documentation
  • Professional ethics 
  • Psychiatric and mental health care
  • Psychiatric hospital surveying 
  • Schizophrenia; Screening
  • Brief Intervention, and Referral to Treatment (for substance use) 
  • Veteran’s issues 
  • And other mental health topics

EXPERIENCEForty-two years’ experience, including child wel­fare services and general community mental health practice:  counseling with children, adolescents, adults, couples and families. 

I meet Washington State requirements as a Mental Health Profes­sional [per RCW 71.05.020(27)] and Children’s Mental Health Specialist [per RCW 71.34.020(2)].

PROFESSIONAL MEMBERSHIPS:  I am a member of the National Association of Social Workers (NASW) and the Academy of Certified Social Workers (ACSW). 

CONFIDENTIALITY

When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of abuse or neglect of children or vulnerable adults; and where a client presents a danger to self. I may be required to disclose the potential threat of harm to others and property (for more details see also the HIPAA Notice of Privacy Practices).  I am not required to treat as confidential a communication that reveals the contemplation or commission of a crime or harmful act.

When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding.  If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by me.  In couple’s or family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members.  I will use my clinical judgment when revealing such information.  I will not release records to any outside party unless I am authorized to do so by all adult family members who were part of the treatment.

Emergencies:  If there is an emergency during our work together, or in the future after termination, when I become concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care.  For this purpose, I may also contact the person whose name you have provided on the biographical face sheet.

Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims.  If you so instruct me, only the minimum necessary information will be communicated to the carrier. Unless authorized by you explicitly, the Psychotherapy Notes will not be disclosed to your insurance carrier.  I have no control or knowledge over what insurance companies do with the information I submit or who has access to this information.  You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance.  The risk stems from the fact that mental health information is entered into insurance companies’ computers.

Confidentiality of Email, Cell Phone and Faxes Communication: It is very important to be aware that email and cell phone communication, including texting, can be relatively easily accessed by unauthorized people and hence, the privacy and confidentiality of such communication can be compromised.  Emails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all emails that go through them.  Faxes can be sent erroneously to the wrong fax number.  Please notify me at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices.

Consultation: I sometimes consult with other licensed counseling professionals regarding my clients in the course of counseling; the client’s name or other identifying information is never disclosed.  The client’s identity remains anonymous, and confidentiality is maintained.

THE PROCESS OF THERAPY/EVALUATION: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy.  Working toward these benefits; however, requires effort on your part.  Psychotherapy requires your active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior.  I will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy, and will expect you to respond openly and honestly.  Sometimes more than one approach can be helpful in dealing with a certain situation.  During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, anxiety, depression, fear, insomnia, sadness, worry, etc.  I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed.  Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. 

Therapy may result in decisions about changing behaviors, employment, environment, relationships substance use, or schooling.  Sometimes a decision that is positive for one family member is viewed quite negatively by another family member.  Change will sometimes be easy and swift, but more often it will be slow and even frustrating.  There is no guarantee that therapy will yield positive or intended results. 

During the course of therapy, I will likely to draw on various theoretical counseling approaches according, in part, to the problem that is being treated and his assessment of what will best benefit you.  My counseling methods and techniques are influenced by the two types of therapy listed below, and an understanding of newly emerging research findings on neurobiological disorders: 

1. Cognitive-Behavioral Therapy challenges a client’s incorrect thinking process.  The basic prem­ise of this ap­proach is that thoughts about a particular event result in feelings, which in turn lead to behavioral responses.  Thus, faulty percep­tions and in­terpretations of an event may cause mal­adaptive responses.  The therapist helps the client change faulty ways of thinking (called "automatic negative thoughts" or ANTS)  that progress to self-defeating feelings and poor behavioral choices.

2. Problem-Solving Therapy focuses on the family unit, emphasiz­ing the social context of human problems.   The goal of ther­apy is to “solve problems, achieve goals, and change the patient’s behavior.”

Remember: As a consumer, you have the right to choose a therapist and treatment modality that best suits your needs.  You have the right to refuse treatment. 

Discussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment, I will discuss with you (client) my working understanding of the problem, treatment plan, therapeutic objectives, and I view of the possible outcomes of treatment.  If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, my expertise in employing them, or about the treatment plan, please ask and you will be answered fully.  You also have the right to ask about other treatments for your condition and their risks and benefits.  If you could benefit from any treatment that I do not provide, I have an ethical obligation to assist you in obtaining those treatments.

Termination:  After the first couple of meetings, I will assess if I can be of benefit to you.  I do not accept clients who, in my opinion, I cannot help.  In such a case, I will give you a number of referrals that you can contact.  If at any point during psychotherapy, I assess that I am not effective in helping you reach the therapeutic goals, I am obliged to discuss it with you and, if appropriate, to terminate treatment.  In such a case, I would give you a number of referrals that may be of help to you.  If you request it and authorize it in writing, I will talk to the counselor of your choice in order to help with the transition.  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, and, if I have your written consent, I will provide her or him with the essential information needed.  You have the right to terminate therapy at any time.  If you choose to do so, I will offer to provide you with names of other qualified professionals whose services you might prefer.

EMERGENCY PROCEDURES: If you need to contact me between sessions in an emergency, please leave a message on my answering machine by calling 360-632-5267; your call will be returned as soon as possible.  In an emergency, after hours, or on weekends, you can call the 24-hour crisis line at 1-800-584-3578.  I check my messages several times a daily, unless I am out of town.  If an emergency situation arises, please indicate it clearly in your message.  If you are suicidal or are having thoughts of harming another person, you should call 911 or go to the nearest hospital emergency room immediately.

PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the standard fee of $150.00 for the initial intake session and $120.00 thereafter per 60-minute individual or family session at the end of each session or at the end of the month unless other arrangements have been made.  The fee for 30-minute sessions is $60.00, and $90.00 for 45-minute sessions.   Payment can be made through medical insurance (I accept most insurances), with cash or check, or by credit card (Visa, Master Card, Discovery, or American Express).  Telephone conversations, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. may be charged at the $120.00 hourly rate, unless indicated and agreed otherwise.  Please notify me if any problem arises during the course of therapy regarding your ability to make timely payments.  Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies.  Not all issues/conditions/problems, which are the focus of psychotherapy, are reimbursed by insurance companies.  It is your responsibility to verify the specifics of your coverage.  For copies of records, I reserve the right to charge $1.12 for the first 30 pages; .84¢ per additional pages; and a $25.00 clerical and handling fee. 

I reserve the right to add a 1% finance charge on overdue balances after 60 days, and the right to send overdue bills to a collection agency after 90 days of non-payment

APPOINTMENT CANCELLATIONS:  Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours (one day) notice is required for re-scheduling or canceling an appointment.  Unless we reach a different agreement, the full fee may be charged for sessions missed without such notification.  Most insurance companies do not reimburse for missed sessions.

MEDIATION & ARBITRATION: All unresolved disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration.  The mediator shall be a neutral third party chosen by agreement of me and the client.  The cost of such mediation, if any, shall be split equally, unless otherwise agreed.  In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Island County, Washington, in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed.  Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, I can use legal means (court, collection agency, etc.) to obtain payment.  The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees.  In the case of arbitration, the arbitrator will determine that sum.

UNPROFESSIONAL CONDUCT: 

You should know that unprofessional conduct is defined in Washington State law in RCW 18.130.180, which can be found on-line at:   http://apps.leg.wa.gov/RCW/default.aspx?cite=18.130.180 

Information requests or complaints about unprofessional conduct should be directed to the Department of Health at:

Health Systems Quality Assurance (HSQA)
PO Box 47857
Olympia WA 98204-7857
Phone:  (360) 236-4700

Email:  QSQAComplaintIntake@doh.wa.gov

Rev. 05/21/2016

Copyright (c) 2017 Robert S. Miller, LICSW, ACSW, PLLC