1
LAUREN R. POLLARD, MA, LMHC
Psychotherapy
TREATMENT AGREEMENT
Client Name: __________________________________________________________________
Your Agreement:
I have received and read Lauren Pollard’s disclosure statement, a separate document, and have
had an opportunity to clarify my concerns and questions with Lauren Pollard. I understand and
agree to all of the policies and procedures.
____________________________________________
Client Signature (or parent/guardian if minor)
____________
Date
I understand that if use my insurance, the insurance company has the right to access my
diagnosis, symptoms, substance abuse issues, as well as documentation of my treatment.
My signature indicates I choose to use my insurance.
___________________________________________
Client Signature (or parent/guardian if minor)
____________
Date
HIPPA Acknowledgment
I hereby acknowledge receiving a copy of Lauren Pollard’s Notice of Privacy, a separate
document.
____________________________________________
Client Signature (or parent/guardian if minor)
____________
Date
2021 Minor Ave. E., Suite 7, Seattle, WA 98102/(206-390-1316)
Washington State Licensure: LH60329791
laurenrpollard@gmail.com
2
LAUREN R. POLLARD, MA, LMHC
Psychotherapy
NOTICE OF RECORDKEEPING POLICIES
In general, I keep two types of information on my clients, Personal Health Information and
Psychotherapy Session Notes. Your Personal Health Information consists of Initial
Documentation and Ongoing Treatment Records.
Initial Documentation:
1. Client Information Sheet
2. Signed copy of my current therapist disclosure form
3. Signed copy of my current statement of confidentiality and signature indicating
receipt of privacy practices
4. Release of information if there is anyone I should speak with about you.
Ongoing Treatment Records
1. A brief note, including date and people involved, for each phone call or therapy
session I have with you
2. A brief note including date and people involved, for any phone call or meeting I have
with a person you have given me permission to speak to
3. A record of any payment I receive
4. A working assessment of presenting problems and a diagnosis, if applicable
5. I may create an outline of significant events in your life history
6. I may create a diagram of your family structure
Psychotherapy Session Notes
Following our therapy sessions I may write more detailed notes regarding discussion topics or
significant events/history that you report. These notes are different than the notes described
above and have specific protections under HIPPA. You have a more limited right of access to
inspect or receive a copy of these notes. I release these notes to a third party only under very
rare circumstances.
*Reduced Records
You may request that I do not keep Psychotherapy Session Notes about you. In this case, I am
still required to keep a minimal record of dates we meet and money you pay me.
*If you prefer that I do not keep session notes, please sign here:
__________________________________________
Client Signature (or parent/guardian if minor)
_____________________
Date
Otherwise, please sign below.
I have read and understand the above recordkeeping policies.
_________________________________________
Client Signature (or parent/guardian if minor)
_____________________
Date
2021 Minor Ave. E., Suite 7, Seattle, WA 98102/(206-390-1316)
Washington State Licensure: LH60329791
laurenrpollard@gmail.com