433 State Street Unit 2
Kirkland, WA 98033
Phone (4525) 827-5095
Fax (425) 827-4802
The information provided below relates to questions that sometimes arise regarding professional and office policies. This form is prepared to provide general information. (Note: Some information may not apply to particular clients.) If after reviewing this form, or at any time thereafter, you have any questions about the professional or business practices of this office, you are encouraged to ask Dr. Montgomery.
About Psychological Services
Psychological assessment and treatment include a variety of methods. In general, all of the methods are aimed at two objectives: 1) Clarifying and understanding the nature and sources of difficulties in the areas of emotion, behavior, and/or thinking; and 2) Planning and carrying out treatment to assist individuals, couples, families and/or groups in achieving greater emotional comfort and/or adjustment. Areas of concern may include, but are not limited to, personal, social, and vocational concerns.
Evaluation methods may include interviews and discussion and/or administration of psychological tests. Treatment generally consists of discussion between psychologist and client(s), with the psychologist applying knowledge of human emotion and behavior to guide the discussion in ways aimed at problem clarification and resolution.
At all times it is important that you have a clear understanding of why you are receiving psychological services, and of how the psychologist is attempting to assist you toward emotional and/or behavioral change. If you are uncertain about this, you are encouraged to ask for clarification.
Dr. Montgomery is an independent practitioner and the name of the practice is for identification purposes. Only Dr. Montgomery is involved in your evaluation and/or therapy.
Ethics and Standards
Dr. Montgomery follows the code of ethics of the American Psychological Association and the ethical and professional standards provisions of the Washington State Psychology Licensing Law
(18.83 RCW and 308-122 WAC.) These documents are available for review in this office.

Dr. Montgomery
Office Policies, pg. 2
If you have any questions or concerns about the treatment you receive in this office please feel free to discuss them with Dr. Montgomery. In addition, or instead, you may contact the
Psychology Licensing Board in Olympia Washington at (360) 753-0776, and/or the Washington
Psychological Association’s Professional Ethics and Standards Review Committee in Seattle at
(206) 363-9772.
Professional Qualifications
Dr. Montgomery holds a doctoral degree (Psy.D.) in applied clinical psychology and is licensed to practice psychology in the Washington State.
Privacy and Release of Information
With three exceptions, as stipulated in Washington law, the fact and content of your professional contacts with Dr. Montgomery are confidential and privileged, and will be disclosed only if he has authorization from you in writing.
The three exceptions are: 1) If Dr. Montgomery believes that there is a danger that you will do harm to yourself or someone else, he is required to inform proper authorities; 2) If there is evidence of child or elder abuse or neglect, Dr. Montgomery is required to report that situation to proper authorities; and 3) Under certain circumstances, if you are a party in a civil litigation or criminal prosecution, disclosure of some aspects of your contact with this office may be required through legal processes under the direction of the court.
In addition, if you are being reimbursed, or if Dr. Montgomery is being paid for services by some third party (for example, an insurance company or state agency) you may have authorized that third party to receive certain information about your treatment in this office, and that information will be provided to the extent necessary to receive payment and as authorized by you. If you have questions or concerns about this, you are encouraged to discuss this with Dr. Montgomery.
Fees and Payment
Dr. Montgomery’s fees for service are as follows: $225.00 for the initial evaluation appointment,
$180.00 for appointments lasting for 55 to 65 minutes, and $150.00 for appointments lasting for
45 to 54 minutes. These amounts may be reduced by the preferred provider discounts given for some insurance plans. Additional charges may be incurred for reports or letters written on your behalf, extended phone consultations, court appearances, etc. These charges may not be billed to insurance and will be billed at $180.00 per hour. Payment is requested at the end of each session unless other payment arrangements are made in advance, or as stipulated by contract with your insurance carrier.

Dr. Montgomery
Office Policies, pg. 3
Unpaid Bills
Accounts not paid according to the guidelines above are both a business and a therapy concern.
If payment is not made as agreed to, there may be anxiety or discomfort that can decrease effectiveness of treatment. If your account is overdue, your psychologist will discuss this with you, and every effort will be made to arrive and a mutually agreeable plan for bringing the account current. In the unfortunate situation that this cannot be achieved, seriously delinquent accounts will be referred to a collections attorney, and the information necessary to assure collection will be released. Should it be necessary to file suit, the client agrees to pay reasonable attorney fees. Monthly late fees will be added to accounts that are past due for more than 60 days.
Cancelations and Missed Appointments
There is no charge for appointments that are canceled more than 24 hours in advance of the scheduled appointment time. Except in the case of an emergency or other unavoidable circumstance, a charge will be made for missed appointments and those canceled with less than
24 hours’ notice.
Insurance
Some, but not all, insurance plans or other health care reimbursement programs cover psychological services. If you have questions about your coverage, contact your insurance carrier to inquire whether your plan covers psychological services. Even if your insurance carrier does cover these services, keeping your account current is your responsibility, and payment at the time of services is expected. Most insurance billing can and will be by Dr. Montgomery’s billing service in an effort to expedite payment and as a courtesy to you.
Professional Relationship
Since trust and clear understanding are of paramount importance in the provision of psychological services, it is Dr. Montgomery’s intention that matters pertaining to your business and professional relationship with this office be explained and discussed openly, and that is the reason for this summary of policies. If you have any questions not addressed by this summary, wither now or in the future, please discuss them with Dr. Montgomery at your earliest convenience.
Records
A record is kept of the psychological services provided to you. You may ask to see that record and/or copy is at your expense. You may also ask that corrections be made to factual errors in the record. Your record will not be disclosed to others unless you direct that it be disclosed or the

Dr. Montgomery
Office Policies, pg. 4 law authorizes or requires that it be disclosed. You may arrange to see or get more information about your record by talking to Dr. Montgomery.
Acknowledgement of Receipt
I have read this document, have had an opportunity to discuss its content with Dr. Montgomery, agree to its terms, and have received a copy if desired.
Client Signature: _______________________________________ Date: _______________
Parent or Guardian: _____________________________________ Date: _______________
(If client is a minor)
Psychologist Signature: __________________________________ Date: _______________
I hereby authorize direct payment of applicable insurance benefits to Dr. Montgomery and the release of needed information regarding my treatment to allow payments to be made.
Client Signature: _______________________________________ Date: _______________
(Parent or guardian if client is a minor)