Christy Stewart, Psy.D. LMHC
3300 E. Union St. Suite 8
Seattle, WA 98122
206-661-2162
Fax 206-400-1133
Consent for Treatment
Description of Practice
I hold a doctorate in Clinical Psychology, as well as an LMHC (Licensed Mental
Health Provider). I have over 30 years of therapeutic experience. My areas of
special interest are trauma and attachment. I work from a developmental,
psychodynamic, social constructivist, and family systems perspective, with
philosophical underpinnings in existentialism. My theoretical orientation
integrates aspects of intersubjective psychodynamic theory, object relations,
attachment theory, developmental psychology, and neuropsychology. Consistent
with my family systems approach, I meet with various family members in support
of the client and for the healthy functioning of the family. I provide family therapy.
This means you can expect me to work on your behalf to help you to identify and
explore feelings, clarify ideas, and create links between emotion, thought, and
experience. I emphasize intersubjective connection (as in Martin Buber’s I-Thou
encounter or the Boston Change Process Study Group’s moments of meeting) as
the essential method of promoting change. It is through working together that
brains change and psychological healing occurs—perceptions shift, selfregulation improves, and development progresses.
I carefully consider issues of attachment, family, larger community, social
systems, trauma, oppression, and cultural diversity. I will not attempt to force
behavioral change before first understanding the meaning and function of
behavior.
As an experienced play therapist, I value play for its metaphoric communication
and integrative and healing capacities. I have taught therapeutic nursery school
at a major hospital, worked with medically fragile children, and with complex
trauma in a residential setting. I provide consultation to daycares and preschools,
and am familiar with adoption and foster care issues.
I conduct psychological assessments for children and adolescents. Psychological
assessment is a powerful means for understanding behavior and psychological
needs. I feel a strong sense of responsibility to accurately and effectively
communicate these needs in psychological reporting.
In all of my work, I strive to be of service. It is my goal to help you achieve
healthy change.
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Confidentiality
All information revealed by you during your therapy is confidential and will not be
shared with anyone without your prior written permission. Concerning a minor
child, the legal guardian holds consent. There are, however, certain
circumstances under which I am required by law to release information without
your prior consent. These are: imminent danger to yourself or other(s), child or
elder abuse, and court subpoena.
If you choose to communicate with me by email or fax, please be aware these
communications are not completely confidential. Records are typically retained in
the logs of Internet service providers. In addition, emails and faxes that I receive
from you, and any responses that I send to you, will be added to your treatment
record.
Recordkeeping
I maintain confidential records of therapy sessions. If you prefer that I do not
keep treatment notes, please give me a written request to this effect for your file.
In this case, I would note in the record the dates you attended therapy, diagnosis,
and the fees involved.
You have the right to a copy of your file. You have the right to request that I
correct any errors in your file. I maintain your records in a secure location, in
accordance of HIPPA requirements.
Fees
$150 per 55-minute psychotherapy session
Psychological Assessment-dependent on actual testing and report writing time
Reduced fee services are available on a limited basis, according to circumstance.
Cash, check, and major credit cards are accepted for payment. Payment is
expected at time of service.
Insurance
I accept First Choice Health Insurance. In addition, I am currently in the process
of being credentialed by Premera and Regence. As soon this process is
complete, I will be paneled by these insurance companies as well (beginning
approximately in February or March, 2015). For other insurance companies, I will
bill for services, but do not guarantee reimbursement. Please contact your
insurance provider regarding reimbursement on insurance panels.
Patient Responsibilities
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Individual therapy sessions are typically scheduled for a particular time
each week. This time becomes your time unless other arrangements are
made.
You are responsible for coming to your session on time. Sessions last 50
minutes. If you are late, we will end on time. If you miss a session without
canceling, or cancel with less than twenty-four hours notice, you are
responsible for that payment at our next regularly scheduled meeting.
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You are responsible for paying for your session at the time of service,
unless we have made other arrangements in advance. Cash, checks, and
credit cards are accepted.
Complaints
If you're unhappy with your therapy, please share your concerns with me. I will
respectfully receive your criticism. Additionally, you have the right to contact the
State of Washington Department of Health, 1300 SE Quince St, PO Box 47869,
Olympia, WA 98504 or call (360) 664-9098.
When your child is the patient
 Psychotherapy works best when patients can trust their therapists to treat
sensitive concerns confidentially. Parents (or guardians) also have a
legitimate need to know how psychotherapy with their child is progressing.
I will ask you to agree to respect the privacy of your child’s treatment
records, but will plan to hold regular parent meetings to keep you posted
on your child’s progress. I will contact you immediately if I believe that
your child’s behavior constitutes a risk to herself/ himself or others. It is
important that we speak about any concerns you may have regarding risky
behavior.
 Consultation with parents (or guardians) is an essential part of
child/adolescent psychotherapy, and I will have a professional relationship
with all of you. From time to time, parents will voice personal concerns in
the course of consulting with me as their child’s therapist. I will gladly
listen to these concerns and assist to the extent I can. However, my
primary role is as therapist to your daughter/son. If your own difficulties
suggest a need for professional help, I will refer you to a skilled colleague.
 Forcing discussion of a child’s psychotherapy in court or legal proceedings
can undermine the therapeutic relationship and prove harmful to the child.
As I begin treating your child in psychotherapy, we all agree that my work
will not involve any evaluation relevant to legal matters. By signing this
form, you agree that you will not call me as a witness to testify in any child
custody matter or other legal proceeding. Should this agreement be
broken my fee is tripled for court-related matters.
The undersigned has read the information above and consents to treatment. My
signature also serves as an acknowledgement that I have received a HIPPA
notice form.
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Patient’s name (please print)
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Patient ‘s signature
Date
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Parent/guardian’s signature
Date
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Psychologist’s signature
Date
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