Kris Coppedge, LMHC, LICSW
20102 Cedar Valley Road, Suite 107
Lynnwood, WA 98036
Notice of Privacy
CONFIDENTIALITY:
All information disclosed within sessions and the written records pertaining to those
sessions are confidential and may not be revealed to anyone without your (client's) written permission, except where
disclosure is required by law.
WHEN DISCLOSURE IS REQUIRED BY LAW: I may use or disclose information without
your consent or authorization under the following circumstances:
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Child Abuse or Neglect: If I have reasonable cause to believe that a child has suffered abuse
or neglect, I am required by law to report this to Children’s Protective Services at the
Washington State Department of Social and Health Services, Children’s Administration,
within 24 hours. If I suspect that a child is imminently at risk of being harmed I am required
to make a report to Children’s Protective Services and to law enforcement.
Abuse of a Vulnerable Adult: If I have reasonable cause to believe that a vulnerable adult,
to include an elderly, or other, or dependent person, is being harmed by abuse, neglect,
abandonment, or financial exploitation, I am required by law to make a report to Adult
Protective Services, Washington State Department of Social and Health Services. If I suspect
that there is a risk of imminent harm to a vulnerable adult, I am required to make an
immediate report to Adult Protective Services and to law enforcement.
Serious Threat to Health or Safety: If I am reasonably concerned that you are at risk of
causing imminent and serious harm to yourself or others, I may legally release information
that is necessary to avoid or minimize such harm. This may include calling 911 or County
Designated Mental Health Professionals.
Judicial or Administrative proceedings: If you are involved in court proceedings, including
custody proceedings, and a request for confidential information is made, I am not required to
release such information without your written authorization, the written authorization of your
legal representative. I am required to provide information when served with a subpoena
when you have been properly informed of such subpoena, or in the case of a court order. I am
also mandated to provide confidential information when providing a court ordered evaluation.
You will be informed prior to the release of confidential information.
Health Oversight: When the Department of Health conducts an investigation regarding the
conduct of another health care provider, or of myself, they may subpoena confidential records
that related to such investigation.
When Disclosure of Confidential Health Care information Requires Authorization:
Protected health care information may be released to a party named by you with your written authorization.
Authorization may stipulate the exact nature of the information to be disclosed and the means used to
disclose that information. Information may also be mutually exchanged when authorization is provided to
the parties who will be exchanging confidential information. Situations when you might request that
confidential information be disclosed or exchanged include:
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Insurance Billing: In order to bill your medical insurance I am required to release
information that will include the type of treatment provided and a mental health diagnosis. If
you do not consent to having this information released, I am unable to bill your health
insurance for services.
Coordination of Care with your Physician or other Health Care Provider: I will ask you
to provide authorization to exchange information with your physician or other health care
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provider if I believe that such exchange is necessary to provide accurate diagnosis or
appropriate care, or if I believe that coordination of services is necessary.
Coordination and Case Management: When providing services to children who have
problems at school, exchange of information with the school counselor and/or the school
teacher may be necessary to develop comprehensive treatment interventions to improve
school behavior, academic progress, and address social skills. Release of confidential
information may be requested when a safety plan is needed for an adult or child whose health
or safety is at risk or when the behavior of an adult or child may pose a risk to others.
Consent Required for Family, Couples, or Group Counseling: You are protected by
health care privacy laws even when participating in family, couples, or group counseling. Your consent is
required to have other people present during your counseling session. You are responsible for the
information that you choose to disclose during family, couples, or group counseling.
Minors and Confidentiality: Children age 13 and older are allowed confidentiality under state law.
I will discuss the limits of confidentiality that I am willing to maintain when working with an adolescent.
My philosophy regarding confidentiality and young people is in keeping with the intent of the law. Young
people are provided confidentiality to enable them to seek help when they may be experiencing abuse or
neglect by a parent or guardian, and to increase the likelihood of help seeking behavior when a youth has a
substance abuse problem or might harm him or herself. I will not provide treatment without consent to
disclose information with parents when I believe that disclosure is necessary to provision of responsible
and professional treatment.
Disclosure when Treating a Client who is Intoxicated: If you drive to a session and appear
intoxicated, I will require that you obtain an alternative form of transportation when leaving your session.
If you drive away from my office and I have reasonable evidence that you are intoxicated, I will call 911.
I have read and understand the information present in this form.
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Client Name (Printed)
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Client Signature
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Date
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Parent or Guardian Name (Printed)
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Parent or Guardian Signature
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Date
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Kris Coppedge, LMHC, LICSW
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Date