Molly Donovan, M.A., LMHC
600 N. 36th St., Suite 321
Seattle, WA 98103
(206) 383-7028
DISCLOSURE STATEMENT
I am pleased that you have selected me as your therapist. This document is designed to tell you
a little about me and clarify important aspects of our professional relationship.
MY BACKGROUND:
I hold a Masters degree in Applied Behavioral Science and systems counseling from the
Leadership Institute of Seattle (LIOS) at Bastyr University. I have done a clinical internship at
Renton Area Youth and Family Services working with children, adolescents, and their families. I
have training and experience using DBT, EMDR, Motivational Interviewing, Narrative, Structural,
Strategic, Solution-focused, and Client-centered models of individual and family therapy. I also
have a special interest in working with creative process. I seek on-going supervision from other
experienced therapists as part of my desire to bring you the best possible care.
I am a Licensed Mental Health Counselor in the State of Washington (LH60160861)
MY APPROACH TO COUNSELING:
I specialize in working with people and their life transitions. When we find it difficult to be at ease
with aspects of our lives or relationships, increasing awareness of our beliefs and patterns can
begin to create possibilities for change. These explorations enable people to move from where
they are, towards the life and relationships they envision for themselves. I believe that good
counseling is a balance between supporting and understanding my client’s experiences, and
challenging them to learn and grow. At times the journey of therapy may feel like “hard work.”
However—joy, fun, and humor are also parts of being human and are important parts of the
therapeutic work I do. I am an attentive and compassionate listener and witness to your
unfolding story of how you are making your way through life. My deep appreciation for the
human desire for connection and sustenance, meaning and safety, informs my creative and
insightful inquiry style that will aid you in moving into greater satisfaction and understanding. My
approach is eclectic and systemic and will be informed by your individual needs.
CONFIDENTIALITY AND PRIVACY:
I will keep confidential anything you say to me, as well as the fact that you are my client, with a
few exceptions as required by law. Please read the attached Notice of Privacy Practices for
more information about your privacy rights.
OUR RELATIONSHIP:
I believe in counseling as a collaborative process between the client(s) and therapist. I greatly
value your input regarding what you feel is helping or not helping in your therapy. I also
welcome any questions you may have during our work together. Although you may at times feel
very close to me, it is important for you to realize we have a professional relationship rather than
a personal one. Professional ethics require that our contact be limited to the paid sessions you
have with me, and that we do not have a social, romantic, or sexual relationship with each other.
FEES AND PAYMENT:
The fee we have arranged for our sessions is $110.00 per 45 minute session. This fee is
payable in cash or check at the beginning of each session. I do not accept medical insurance
for payment.
However, I will provide you with an invoice that you can submit to your insurance company.
2
Continued
APPOINTMENTS AND CANCELLATIONS:
I keep my own appointment book, so to schedule or change an appointment, call me at (206)
383-7028. If I am not available, please leave a voice mail including phone numbers and good
times to call you back.
If you need to cancel an appointment, please notify me at least 24 hours in advance. If you do
not show for an appointment, you will be charged a “No Show Fee” at your regular rate. If you
call and cancel with less than 24 hours notice, you will be charged a “Late Cancellation Fee”
at your regular rate.
EMERGENCIES:
If you need to contact me urgently between sessions, call me at (206) 383-7028. If a phone
contact of more than 10 minutes is necessary, a fee will be charged at my usual hourly rate.
If you are unable to reach me when you feel the need for some emergency help, please call the
24-hour Care Crisis Line at (206) 461-3222. In the case of a life-threatening emergency,
please call 911 or go to the Emergency Room.
ETHICS AND PROFESSIONAL STANDARDS:
I honor all regulations in the Counselor Credentialing Act (18.19 RCW). The purpose of the law is:
(A) To provide protection for public health and safety
(B) To empower the citizens of the State of Washington by providing a complaint process against
those counselors who would commit acts of unprofessional conduct. You have the right to
choose counselors who best serve your needs and purposes.
As a psychotherapy client you have privileged communications under state law. With the exceptions of
situations listed below, you have the right to have information shared in therapy sessions to be held in the
strictest confidentiality, including the fact that you are seeing me for psychotherapy. The privilege is
yours, not mine, and cannot be waived without your written consent. I will always act to maximize your
privacy even when you waive your confidentiality.
The following are exceptions to your right to confidentiality:
1) If I believe that you are likely to do harm to yourself or to another person, I am required by law to take
steps to protect you and/or the other person.
2) If I believe that you may be physically or sexually abusing or neglecting either a minor child or a
vulnerable adult, or if you report information to me about the possible abuse of a minor child (under 18
years of age) nor vulnerable adult (one who is dependent upon another adult for physical and/or
emotional caretaking, unable to do so for themselves), I am required by law to report this to either Child
Protective Services or Adult Protective Services, state agencies.
3) If you submit claims to your insurance company, they will likely require some information regarding
your treatment with me. You have the right to know the diagnosis that I may use in communication with
them or their related third-party payer. All diagnoses I use are found in the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV), Fourth Edition. A copy of this book is available in my library and
you are free to read it.
4) The court may require such information and at that point we would discuss together how to proceed.
For specific details about exceptions, please refer to the Counseling or Hypnotherapy Clients brochure
provided to you. Should disclosure of confidential information be necessary, I will work with you as
respectfully and directly as possible.
If you have any concerns about your experience, please discuss it with me. If you feel I have been
unethical or unprofessional, you can contact the Washington State Department of Health, Health
Professions Quality Assurance Division, PO Box 47869, Olympia, WA 98504-7869. You may also call
(360) 236-4902 Mondays through Fridays 8AM to 5PM.
.
3
“Counselors practicing counseling for a fee must be registered or certified with the department
of health for the protection of the public health and safety. Registration of an individual with the
department does not include recognition of any practice standards, nor necessarily implies the
effectiveness of any treatment.”
____________________________________________________________________________
I have received and reviewed the Client Disclosure Information and the brochure, Counseling or
Hypnotherapy Clients. I have had the opportunity to ask any questions regarding this material
and understand the information provided. I am of sound mind and body, participate voluntarily,
and understand that I am personally responsible for my experience.
_______________________________
Client's Signature
_______________________________
Therapist’s Signature
_______________________________
Printed Name
_______________________________
Date
_______________________________
Date