Shannon Sprung, MA, LMHC
Licensed Mental Health Counselor
Washington License #LH60595294
Informed Consent and Disclosure
Services
My goal is to create an environment in which you can feel comfortable enough to investigate
behavior, thoughts, and emotions that may be creating undesirable patterns in your life. My
approach to psychotherapy is based on the belief that each person has the innate ability for
healing and personal growth. My role is to assist each client in their unique and individual
process of discovering those abilities.
The duration of our work together is dependent on a number of factors including your level of
commitment, goals, time frame, and rate of progress. It should be noted that psychotherapy
resulting in lasting change is often a long-term process and can lead to difficult feelings of
anger, depression, anxiety, or fear, among others. Please discuss any issues, concerns, or
questions you may have in regards to treatment.
Therapeutic Orientation
There are many different approaches to the therapeutic process and my style is an eclectic
one. I draw from a variety of theories, including (but not limited to): psychoanalysis, emotion
focused therapy, contemplative psychotherapy, mindfulness techniques, feminist therapy,
relational psychotherapy, and internal family systems. I will work with you to provide you with the
most appropriate interventions for your particular issues and goals. Please discuss any concerns
or questions you have regarding theoretical orientation or your treatment with me at any time
during the therapy process.
Sessions typically last 50 minutes. They are expected to begin promptly and end at the
scheduled time. Please be aware that if you arrive late for your session, we will still end at our
regularly scheduled time. I commit to being on time and will offer appropriate remedy if late.
Education and Training
I am a licensed mental health counselor (LMHC) in the state of Washington, license
#LH60595294. I graduated from St. Edward’s University in Austin, Texas with a Master of Arts in
Professional Counseling in 2009. During my graduate school career, I completed two semesters
of direct client counseling at a non-profit organization in Austin, Texas. Post graduation, I opened
my private practice. During the first two years of running my private practice, I provided probono counseling at a low-income/low-cost counseling center as well as at a non-profit LGBT
youth center. I also provided counseling through Child Protective Services (CPS). I have a wide
array of therapy related knowledge and abilities, but specialize in transgenderism, gender
variance and sexual orientation. In addition, my therapeutic focus encompasses topics that
include polyamory, sexual trauma and abuse, feminine empowerment, anxiety and depression.
Your Rights as a Client
You have the right to choose a counselor that best fits your needs and you have the right to
terminate services any time you choose. If you feel we are not a good fit, please understand
that you may bring this to my attention so that we can openly discuss your concerns (although
this is not a requirement). If we find termination of services to be the best option, I will offer
referrals. You will be responsible for any outstanding balances at that time. You have the right for
further explanation of these policies at any time.
You have the right to know the content of your records at any time,. Please note your request
must be in writing.
650 South Orcas Street, Suite 218 ▪ Seattle, WA 98108 ▪ (512) 554-2402
Shannon Sprung, MA, LMHC
Licensed Mental Health Counselor
Washington License #LH60595294
You have the right to ask questions about any of the procedures used in the course of your
therapy. If asked, I will explain my customary approach and methods to you.
If you have concerns about the treatment you are receiving or my behavior, please feel free to
discuss this directly with me. If you feel I have been unethical in my treatment or behavior, you
have the right to contact the Department of Health: Health Services Quality Assurance Division,
PO Box 47857, Olympia, WA, 98054; 360-236- 4700 or via email:
HSQAComplaintintake@doh.wa.gov.
Confidentiality
Your records and payment information will be kept confidential and be stored in a HIPAA
compliant file box. Information revealed by you during the course of therapy will be kept
completely confidential and will not be revealed to any person without a signed release from
either the client or the parent/legal guardian of a client less than 13 years of age. However,
counselors are mandated reporters and there are times when I may be required or allowed to
disclose confidentiality Information. Information related to the following situations may be
released without your consent:
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Disclosure of abuse or neglect of a child or dependent elder (physical, emotional,
sexual)
If I reasonably believe that my disclosure will avoid or minimize an imminent threat to you
or to a third party
Involuntary mental health commitment due to need for assessment
A court or other documented state agency has ordered me to do so
If you bring a complaint against me
Payment
Fee for service is $125/50-minute session. Additional time is billed to the quarter hour. With regard
to payment for services:
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Payment is due at the time of service delivery in the form of cash, check, or
credit card.
You agree to pay a $25.00 service charge for each returned check.
If you and I have arranged payment based on a sliding scale, you agree to notify me of
changes in your income or household size.
I do not accept insurance as payment. However, if you would like to file with your insurance
company for reimbursement, I am happy to provide you with an itemized receipt.
Missed Appointments and Cancellations
Since services are by appointment only, this time is reserved exclusively for you. If you will be
charged the full session fee _____________ (initial).
Communications
You may call 512.554.2402 for any questions regarding billing or appointments. Therapeutic calls
during business hours (Monday–Thursday 8am–7pm, excluding holidays) lasting more than 10
minutes are billed prorated at my regular fee. Skype, VSee, and/or FaceTime sessions are billed
at the regular hourly rate. You may also contact me via e-mail at shannonsprung@gmail.com.
Forms of technological communication (cell phone, e–mail, Skype, and other forms of internet
communications), are not secure/confidential forms of communication and do not guarantee
confidentiality. By signing this form you are allowing me to use these forms of communication.
650 South Orcas Street, Suite 218 ▪ Seattle, WA 98108 ▪ (512) 554-2402
Shannon Sprung, MA, LMHC
Licensed Mental Health Counselor
Washington License #LH60595294
You agree not to hold Shannon Sprung, MA, LMHC, legally responsible for the transmission of this
data.
Therapeutic Relationship/Public Encounters:
The relationship between therapist and client is the vehicle through which client change can
take place. As such, it is often one in which close emotional bonds develop. It is also a
professional relationship in which appropriate boundaries must be maintained. For the most part,
the therapeutic relationship begins and ends at the therapy office. Although this is sometimes
difficult to understand, it is a necessary requirement for maintenance of the therapeutic
environment.
If we happen to see each other in public, your confidentiality will be protected, and I will follow
your lead. If the situation feels uncomfortable and you choose not to greet me, I will act in kind.
If you choose to greet me, I will respond. If others ask about our affiliation, that will be your
question to answer.
Please also note that I do not accept friend requests on social media sites from current or former
clients. Doing so may compromise your confidentiality and privacy.
Confidentiality with Regard to Minors:
The parents or legal guardians of my clients under the age of 13 have the right to access their
child’s psychological records. I will discuss with you the limitations, procedures, and implications
with regard to your child’s records and progress. When I consult with parents regarding children
and adolescent clients under age of 13, specific content of the therapy sessions should ideally
be held in confidence in order to create the safest possible space for the necessary therapeutic
work to be accomplished. Please be aware that should any of the issues rise to the level of
serious, imminent danger to self or to others, I will notify parents and/or appropriate authorities.
Professional Consultation
In order to maintain the quality of your care, I consult with seasoned colleagues regarding
treatment of clients. Please understand your circumstances will be generalized, and all
identifying information will be concealed in order to maintain complete confidentiality.
Vacation
When I go on vacation, I will provide you with advanced notice so that you can plan for the
continuity of your therapy. If you would like the contact information for an alternate therapist to
schedule an appointment in my absence, please let me know. If a crisis arises during this time,
you may call the alternate therapist, the Seattle Crisis Clinic’s 24-hour hotline at (866) 427-4747, or
911.
Court Requested Support
In order to avoid dual relationships and conflicts of interest, I will provide you or your child with
clinical services only. I do not intend to become involved in legal disputes such as personal injury
lawsuits, divorce proceedings, dependency hearings or custody battles. These proceedings
erode the client-therapist relationship and compromise you or your child’s ability to be honest
during treatment. In addition, I do not participate in evaluation for adoption home studies or
evaluations of parental fitness to adoption or State agencies. By signing this document you
agree:
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That my role is limited to providing treatment and that you will not involve me in legal
disputes;
650 South Orcas Street, Suite 218 ▪ Seattle, WA 98108 ▪ (512) 554-2402
Shannon Sprung, MA, LMHC
Licensed Mental Health Counselor
Washington License #LH60595294
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That you will instruct your attorneys not to subpoena me or refer in any court filings to
anything I have said or done;
That you will not ask for my participation or recommendations in any adoption or
dependency;
If there is a court-ordered evaluator in your child’s custody/dependency dispute, and if
appropriate releases are signed and a court order is provided, I will provide general
information about you/the child which will not include any recommendations to
custody/visitation;
If for any reason I am required to provide expert testimony or documentation for a legal
dispute, the party responsible for my participation agrees to reimburse me at $250 per
hour, regardless of sliding scale session rate, to cover time, travel, reports, and other
case-related costs.
In Case of Emergency
If you are in crisis, please call the Seattle Crisis Clinic’s 24-hour hotline at (866) 427-2727 or 911.
Please be aware that I am not a crisis facility and will not be held responsible for any damages
occurring as a result of unmet crisis or acute care needs. I may not be available to respond to
emergency situations.
transMISSION wellness
Please note that I am operating as an individual entity (Shannon Sprung, MA, LMHC). I am doing
business under the shared name, transMISSION wellness, as a way to market and convey a
shared mission statement that commits to providing services with respectful and nonjudgmental
views towards, maintain a safe space for, and continue to self-educate regarding all genders,
all sexualities, and all relationship styles.
I have read and agree to the policies above.
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Client (or Legal Guardian) Printed Name
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Date
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Client (or Legal Guardian) Signature
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Date
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Shannon Sprung, MA, LMHC
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Date
650 South Orcas Street, Suite 218 ▪ Seattle, WA 98108 ▪ (512) 554-2402