Lokahi Counseling & Consulting
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Professional Disclosure Form
Before entering into a counseling relationship, it is imperative that the client receive pertinent information about the counselor. This is the purpose of a counselor's professional disclosure form.  The disclosure form will tell the client where the counselor received his or her education, training and experience, and will outline the counselor's approach to treatment. The form will also address ethical issues such as the limits of confidentiality and informed consent, and will tell the client what to do if there are any concerns about treatment. Office policies and methods of payment are also addressed.     

View Tracy's Professional Disclosure form here:

  
Lokahi Counseling and Consulting Services   Tracy C. Kenela, M.A., CRC, CDMS Therapist / Business Consultant / Public Speaker
WA State Registered Counselor #00055108 
Disclosure Statement This Disclosure Statement offers general information about me and my counseling practice, and additional information required by Law. Please take a few minutes to read through this statement. If you have any questions, please feel free to talk with me about your questions prior to signing.  
My Background I earned a Master of Arts Degree in Clinical Psychology (Marriage and Family Therapy) from Chapman University in 2007, a Bachelor of Arts Degree in Organizational Behavior from The Evergreen State College in 2002, and an Associate of Arts Degree in Accounting from South Puget Sound Community College in 1991.  I received internship training from Behavior Health Resources (BHR) in Olympia, WA, where I provided mental health counseling to children, families, adults and groups. I was also employed as a Vocational Rehabilitation Counselor for over five years, and currently hold two national certifications – one as a Certified Rehabilitation Counselor (CRC), and the other as a Certified Disability Management Specialist (CDMS).  I have written three articles that were published in peer-reviewed journals: One was to call attention to the dangers of herbal cigarettes, one was about rehabilitation counseling trends, and one was about job burnout in counselors. I am currently a Registered Counselor in Washington State, and I co-facilitate a weekly eating disorders support group in Olympia, Washington while working full time as an employee of the Washington State Department of Labor & Industries as a Vocational Counselor Auditor.  
Theoretical Orientation and Approach My approach to counseling is based on the belief that you have the power within yourself to work through painful, confusing and chaotic situations and develop a plan to live a meaningful life.  This is achieved by using a unique combination of existential and cognitive behavior therapy models. Therapy includes examining how you currently see yourself functioning in the world, uncovering the true sources of your pain or current situation, discovering how you would like your life to look, and exploring how you would like to see your life change. My role in this process is to encourage you to use your freedom and creativity to discover how you would like your life to look, and to provide you with some practical tools so that you can make the changes necessary to begin living a more satisfying and meaningful life. 
Confidentiality As a therapist, I make your confidentiality my highest priority so that you will be able to do your work in an environment that is safe. There are a few guidelines, as well as professional ethics, that clarify how your health information will be protected by me, and when I can make disclosures to third parties. For example, Washington State law requires me to break confidentiality and inform the appropriate agency or person in the following situations: 1) if I believe that your life or someone else’s life, safety or property is threatened or endangered; 2) if there is evidence or even suspicion of physical or sexual abuse or neglect of a minor child, dependent, developmentally disabled adult or elderly person; or 3) if a judge orders certain information disclosed in a legal proceeding. In legal proceedings when your psychological health is at issue (e.g., work related stress, divorce /custody battles, etc.) the attorney for the opposing side may have certain information subpoenaed. In that case, I would inform you of the subpoena. If you object to my complying with the subpoena, I may still be required to turn over the information, but only if ordered by a judge or otherwise required by law.  Although I may occasionally meet with one person separately, Family Systems Theory says that the couple or family is the real client.  My loyalty must be, and is, with that total client.  Because healthy families practice open communication, if I meet with one person alone and he or she reveals important secrets, I must ethically help the person share that secret with the others or reveal it myself.   As part of good professional practice, there are times when I consult with colleagues on some therapeutic issues. When I do this it is with considerable caution and respect for your confidentiality.  With these few exceptions (also listed in the attached brochure), I will divulge information from our counseling sessions only with your written consent.   
Course of Treatment The course of treatment for effective counseling (including both frequency and duration) varies widely depending on a client’s needs. If you are in crisis or are working on deeply embedded issues that are significantly impacting your life, we may want to meet on a weekly basis. If your needs are less urgent, meeting for sessions every two weeks may work well for you. Others prefer monthly or even quarterly “check-ups.” The duration of treatment may range from a few sessions for addressing short-term goals, to several months or longer for deeper issues. During our first session, we will make an initial plan for your course of treatment.
Informed Consent and Feedback In the interest of full disclosure, it should be noted that there are risks in any of the treatment methods I employ, including failure to relieve emotional distress. Of course, failure to receive treatment also leads to risks, including continued emotional distress. There are numerous other forms of mental health treatment based on different theories and techniques, as well as medical interventions that may also relieve emotional distress. I ask that you be an active participant in your treatment – including deciding when treatment is or is not effective.  I consider myself a consultant to you. As such, you are hiring me with a specific goal in mind. I always appreciate and am open to feedback regarding your needs and goals and evaluation of the therapeutic process. If you are dissatisfied with the direction of therapy or any particular session, please let me know. You have a right to ask questions or request changes in the therapeutic process. At any point, you have the right to take a break from therapy, discontinue therapy, or request a referral to another therapist. If you do wish to take a break, discontinue therapy, or transfer to another therapist, please talk with m e about it so that we can allow for appropriate closure or transition by talking about your experience, your progress, and your plans to solidify your progress outside of therapy.  If you believe that an act I have committed is unprofessional, I strongly encourage you to talk with me about your concerns. If, having done this, you feel your concerns are still unresolved, it is your right to notify the American Counseling Association (ACA) about your concerns and /or register a formal complaint against me.
 Office Policies Appointments and Cancellations: Appointments for standard fifty-minute counseling sessions can be made by telephone. Twenty-four hours notice is required if you need to cancel your appointment, so that I may offer that opening to another client. With the exception of emergencies and unexpected illnesses, if you do not show up for an appointment, you will be asked to pay a $20 no-show fee. You may leave cancellation information on my voicemail. I will be happy to return your call to reschedule your appointment.  
Emergencies: I check my confidential voicemail messages each working day. If you need to speak with me, please call and leave information about where I can reach you, and I will call you back at my earliest opportunity. If you feel your need is more urgent, please contact the Crisis Line at (360) 586-2800 or dial 911 for immediate help. 
Extended Leave: If I am out of the office for an extended time (vacation, training, etc.) I will leave information on my voicemail about whom you may contact if you need to see someone before my return. 
Counseling fees: At this time, my ability to accept insurance is limited.  My standard rate is $70 per hour. Although I cannot bill your insurance,   I will honor your insurance co-payment amount for a limited amount of time if you present me with verification that your insurance covers mental health services. A sliding fee scale is available for those who are in financial crisis. The per hour rate on the sliding fee scale is calculated at .001 x annual or family income. (For example, $36,000 per year income would be $36 per hour).  My minimum hourly rate on the sliding fee scale is $30 per hour. I also offer pro bono spots, scheduled at low demand times during the day. These hours are very limited, as they do not exceed 10 percent of my total practice hours.I can also offer half-hour times to clients for half fee. In these sessions, we focus on quickly assessing the issues at hand, and developing crisis-centered action plans.   Payment is due at the time of each session in the form of cash or check. At this time, I cannot accept credit or debit cards as methods of payment.
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Washington State Law requires that the following language appear on every disclosure statement: “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 a recognition of any practice standards, nor necessarily implies the effectiveness of any treatment.”  “The purpose of the Counselor Credentialing Act (Chapter 18.19 RCW) is (A) To provide protection for public health and safety; and (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.” 
Agreement Please sign below to indicate that you have read and understand all of the information in this disclosure,  including the following: 1) all of the limits to confidentiality, 2) that in cases of family counseling, you give me permission to share any one individual’s secrets with other individuals in the family if necessary, 3) you understand that I am also employed at the Department of Labor & Industries as a Vocational Counselor Auditor and 4) that I have given you a copy of the State brochure entitled "Counseling or Hypnotherapy Clients."