Disclosure Statement
Ying Yu, MS, CN, LMHC
Welcome! I’m glad you chose to meet with me. I look forward to working with you to make many
positive changes in your life. The purpose of this document is to let you know what you can
expect from my services. Please ask questions. It is important to me that you have clear
understanding of the information provided here.
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CONFIDENTIALITY
Whatever you share with me during a private session is confidential information. I will not
disclose personally identifying information about you to anyone outside of my office without your
written permission. In order to provide you with the best service possible, I may seek supervision
and consultation from other health professionals. These professionals have the same obligation
to maintain confidentiality that I do.
From time to time, I may ask to audio record our sessions for my personal review and record
keeping only. I will always ask for your permission in advance and these recording will not be
shared with anyone outside my office without your written permission.
Exceptions to Confidentiality
Exceptions to confidentiality are meant to protect your interests and the interests of others. Only
in the following circumstances would I be obligated by law to release confidential information:
 If I become aware of physical or sexual abuse of a child or dependent adult
 If you give strong indications that you are likely to seriously harm yourself or another
 If I am served with a court order to share information with a judge or lawyer
I will encourage you to be the active person in making reports regarding abuse or self-harm. If I
am obligated to release information, I will inform you of my intentions whenever possible.
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TECHNIQUE OF COUNSELING
Because food affects all areas of our life, my therapeutic approach is holistic, integrating
nutritional counseling with mental health counseling. While much of our work together will focus
on getting your nutritional and physical health on track, this process can uncovered conscious and
unconscious emotional, mental, and spiritual patterns that prevent you from converting
knowledge into action and/or from making lasting change. With your permission, we can explore
these patterns together through deeper counseling work (see below for details). I can also
provide strictly nutritional counseling or mental health counseling upon request. My goal for our
time together is to provide you with a “container” and structure for exploring and cultivating
mind-body nourishment practices in your daily life, so that you can sustain a lifetime of health and
balance, no matter what stressors come your way.
Nutrition Services
I am a Certified Nutritionist with the State of Washington and a Certified Holistic Health Coach
with the American Association for Drugless Practitioners. I earned my Master’s in Clinical
Nutrition from Bastyr University and Certification in Holistic Health Coaching from Institute for
Integrative Nutrition. In our sessions, we will address your clinical and subclinical health concerns,
nutrient deficiencies and excesses, lifestyle factors, and self-care patterns in a way that respects
your cultural, socioeconomic and taste preferences. Treatment can involve food and supplement
recommendations, lab analysis, grocery shopping together, cooking together, as well as referrals
and collaboration with outside providers. With a background in eastern and western dietary
theories, I may also incorporate traditional Chinese and Ayurvedic principles into your treatment
plan.
Psychological Services
I am a Licensed Mental Health Counselor with the State of Washington. My education includes a
Master’s degree in Clinical Health Psychology from Bastyr University and a Bachelor’s degree in
Psychology from Amherst College. I completed a one-year clinical mental health internship at
Asian Counseling and Referral Service, as well as all coursework required to become a Chemical
Dependency Professional through NW Indian Community College. I am a member of the Seattle
Counselor Association, and I am bound by Washington State codes of practice. The theoretical
orientations I use include Buddhist Psychology, Jungian Psychoanalysis, Dialectical Behavioral
Therapy, and Object-Relations. This means that I focus on helping individuals develop greater
awareness and insight into their maladaptive patterns, and better coping skills around distressing
emotions and situations that interfere with healing. Areas that we may explore together include
(but are not limited to) empowering and disempowering beliefs and experiences around food,
exercise, body, self-worth, lapses and relapses, success and failure, spirituality, relationships
(including the client-clinician relationship), career, and change. Because open and transparent
communication is essential to the effectiveness of treatment, I encourage regular constructive
feedback from you on how this process is going for you, so that we can continually modify and
optimize your treatment plan as you progress.
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APPOINTMENT AND FEES
Appointments are scheduled in advance and generally take place once a week or every two
weeks, but can be altered depending on your needs. Sessions are 50 minutes long.
My standard out-of-pocket rates (for those without insurance) are as follows:
$175
$145
$270
$520
$750
$1495
$1440
$2880
Initial assessment
Single follow-up session
2 bimonthly sessions (with sign up for a 3-6 month personalized program)
4 weekly sessions (with sign up for a 3-6 month personalized program)
3 Month Package (6 bi-monthly sessions)
3 Month Package (12 weekly sessions)
6 Month Package (12 bi-monthly sessions)
6 Month Package (24 weekly sessions)
(For additional services and programs offered, see attached fee schedule.)
Payment is due at the beginning of the session, month, or program. You may change the
frequency of sessions at any time between billing cycles and fees will be adjusted accordingly.
I am an in-network provider with the following insurance companies:
Nutritional Services: Regence, Providence Health, Premera, Lifewise, First Choice, Cigna,
Aetna, and Uniform (diabetes only)
Mental Health Counseling: Regence, Uniform, Providence Health, United
For clients whose insurance policies reimburse for consultations with out-of-network
practitioners, I am willing to provide receipts for them to send to their providers.
My fee applies to telephone contacts beyond 10 minutes per week. When a call goes over 10
minutes, I will let you know that you can either continue our conversation during a session or
begin charging you the pro-rated fee. You may leave a message for me at any time.
I provide unlimited email support between sessions for quick 5-10 min responses. My fee applies
to email questions that take longer than 10 minutes to respond. If I anticipate an e-mail response
taking more than 10 minutes, I will let you know that we can either discuss it during a session or I
can respond at a pro-rated fee.
If you are unable to keep an appointment, please notify me at least 48 hours in advance. You will
be charged $100 for scheduled sessions that you do not show up for or call to cancel with
appropriate notice.
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EMERGENCIES
In case of emergency when I am not available, please call the Crisis Clinic (if you live in the Seattle
area) at (206) 461-3222 or the police at 911.
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Fee Schedule for Services
Appointments with Nutritionist


Some appointments may be with culinary expert or associate nutritionist
All prices are for individuals. Couples are 1.5 times the price, and groups are determined.
-Intake/first appointment
$255 (55-70 minutes on average)
$175 (out of pocket discounted rate)
-Follow-up sessions
$231/hour
$145/hour (out of pocket discounted rate)
-Monthly - 1 session/week* (4 total)
$520
($130/session)
-Monthly – 2 sessions/week* (2 total)
$270
($135/session)
-3 Month Package - 1 session/week* (12 total)** $1495
($125/session)
-3 Month Package - bi-monthly* (6 total) **
($125/session)
$750
-6 Month Package - 1 session/week* (24 total)** $2880
($120/session)
-6 Month Package - bi-monthly* (12 total)**
($120/session)
Appointment with associate nutritionist
$1440
$110/hour
(not covered by insurance, upon recommendation)
Menu planning/meal creation
$55/hour
Private cooking class
$95/hour, $110 for two people
Monthly group cooking class (max 6/class)
$45/person, $75 for two people
Grocery tour/ pantry overhaul /cooking trio package
$175 for one person,
$195 for two people (one pantry only)
(personalized, private cooking class)
Private Grocery Store Tour (3 people max)
$75/hour
*Monthly packages must be used within 7 weeks, 3 month packages need to be used within 4 months,
6 month packages need to be used within 7 months.
**3 and 6 month packages may be paid on a monthly basis (at the beginning of each month). Outstanding payments must be paid
upon package end-date.
April 1, 2013
HIPAA Statement
As a patient of Ying Yu, MS, CN, LMHC, you have the right to adequate notice of the uses and
disclosures of your protected health information.
Ying Yu, MS, CN, LMHC will use and disclose your health information in order to treat you or to assist
other health care providers in treating you, to obtain payment for services or allow insurance
companies to process insurance claims for services rendered to you. Information could be disclosed
for certain limited operational activities such as quality assessment, licensing, accreditation, and
training of students.
Except as stated in more detail in the Notice of Privacy Practices, Ying Yu, MS, CN, LMHC will not use
or disclose your health information without your written authorization.
Uses and disclosures not requiring your written authorization include:
 To family members or close friends who are involved in your health care
 For certain limited research purposes
 For purposes of public health and safety
 To government agencies for purposes of their audits, investigations and other oversight
activities
 To government authorities to prevent child abuse or domestic violence
 To the FDA to report product defects or incidents
 To law enforcement authorities to protect public safety or to assist in apprehending criminal
offenders
 When required by court orders, search warrants, subpoenas and as otherwise required by law
PATIENT RIGHTS:
 To have access to and/or copy of your health information
 To receive an accounting of certain disclosures made of your health information
 To request restrictions as to how your health information is used or disclosed
 To request that communication with you be made in confidence
 To request amendment of your health information
 To receive notice of privacy practices
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DEPARTMENT OF HEALTH CONTACT
To obtain a copy of your rights as a client in the state of Washington, as well as a list of the acts of
unprofessional conduct in my field for which a health professions complaint may be processed,
contact the Department of Health–Counselor Programs, PO Box 47869, Olympia, WA, 98504, or (360)
664-9098.
AGREEMENT
By signing this form, I acknowledge that:
 I agree to participate in services with Ying Yu, MS, CN, LMHC
 I have read the above information and received the summary of HIPAA (Health Insurance
Portability and Accountability Act).
 I have had an opportunity to ask questions to clarify my understanding of the information.
 I understand that I have the right to refuse treatment and the right to choose a
practitioner and treatment modality which best suits my needs.
 I agree to pay for services according to the fee guidelines outlined above.
Client name: ___________________________________
Signature:
___________________________________
Date:
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