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Terms and Policy

Informed Consent
This form is to ensure that you have information about me and the work we will be doing together, in addition to understanding office policies. I am happy to answer any questions you have at any time now or in the future. It is a bit weird reading this long form in this tiny box--sorry about that. You will be able to print this out when you are done if you wish.

Stephanie Sisson: background and approach

I received my BA from Pomona College in 1990 and my MSW (Master in Social Work) from UCLA in 1996. My initial training was in working with children and families and I worked for a number of years at a residential treatment center for emotionally disturbed children. I am licensed in the state of Washington as a Licensed Independent Clinical Social Worker and am a member of the National Association of Social Workers. I received my yoga teacher certification in 1997 and taught yoga for over 15 years.

After moving to Seattle in 2000, I began combining yoga and therapy to work in a more holistic way. I worked for almost eleven years at The Samarya Center in an approach called Integrated Movement Therapy. It is a very strength-based approach that incorporates movement and other techniques from yoga to aid in healing. While at The Samarya Center, I worked with people of all ages and facing a wide range of conditions and challenges. I also trained other therapists in IMT and supervised the clinic there, overseeing and advising the other therapists.

In working with clients now, as appropriate in my clinical judgment, I primarily use Somatic Experiencing (SE), described below, either in a basic way to support stabilization or in a more in-depth way to work with trauma. I combine SE with cognitive-behavioral techniques and approaches, as well as conventional supportive counseling.

SE is a naturalistic approach to the resolution and healing of trauma developed by Dr. Peter Levine and is supported by research. It is based upon the observation that wild prey animals, though threatened routinely, are rarely traumatized. Animals in the wild utilize innate mechanisms to regulate the high levels of energy arousal associated with defensive survival behaviors. These mechanisms provide animals with a built-in "immunity'' to trauma that enables them to return to normal in the aftermath of highly "charged'' life-threatening experiences.

— --SE employs awareness of body sensation to help people "renegotiate" and heal rather than re-live or re-enact trauma.
— --SE's guidance of the bodily "felt sense," allows the highly aroused survival energies to be safely experienced and gradually discharged.
— --SE may employ touch in support of the renegotiation process.
— --SE "titrates" experience (breaks down into small, incremental steps), rather than evoking catharsis - which can overwhelm the regulatory mechanisms of the organism.

For more information about SE please note the following references:
Levine, P. and Frederick, A. (1997). Waking the Tiger: Healing Trauma : The Innate Capacity to Transform Overwhelming Experiences. Berkeley, CA: North Atlantic Books.
Levine, P. (2010). In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley, CA: North Atlantic Books.
For further references and information online about SE go to

SE can result in a number of benefits to you, such as relief of traumatic stress symptoms, increased resiliency, and resourcefulness. Like any other treatment it may also have unintended negative side effects, such as sleep disturbances, frightening memories, or unfamiliar and uncomfortable body sensations. Such reactions are not uncommon and can be attended to in the course of our work together. It is important that you are aware that there are other forms of body-oriented and somatic psychotherapy modalities that may also be helpful to you, such as EMDR, Sensorimotor Psychotherapy, or Bodynamics. Obviously, there are also many non-somatic focused forms of psychotherapy and counseling that you can choose from.

My own education and training in SE includes completing the three-year SE training in October, 2013. I have been using SE in my practice since I began the training in 2011. I have taken many additional workshops and trainings in SE, including about 200 hours on the use of touch to work with trauma and support nervous system regulation. I have consulted with Somatic Experiencing Practitioners throughout my training and continue to seek consultation in order to provide the best treatment to my clients. In addition, I assist at SE trainings in order to continue my own learning.

It is your responsibility to tell me when you are uncomfortable with any parts of the treatment. If you have any questions about SE or other treatments, please ask and I will do my best to answer your questions. You have the right to refuse or terminate treatment at all times, or to refuse touch, SE techniques, or any other intervention I may propose or employ.


I must keep notes of your therapy sessions, but they are kept completely confidential. Your written authorization is required for any release of information or records. Mandated exceptions are: court orders, imminent danger to you or another person, or suspected abuse of children, the disabled, or elderly. In order to provide you with the best treatment, I consult with colleagues and teachers, but will not reveal identifying information.

Payment and Cancellations

Payment is due at the time of the session.

The fee is $120 for a 60-minute session. If paid in full at the time of the session, the discounted fee is $100. We may discuss sliding scale fees.

There is a 24-hour cancellation policy. For cancellations within 24 hours of the appointment, there will be a $60 late cancellation charge. No shows will be charged the full session fee.

I accept First Choice Health, Premera, LifeWise, Regence, Blue Cross Blue Shield and some Kaiser PPO insurance. If you have one of these plans, you can enter your insurance information by going to "billing" in the menu and then choosing "insurance."

I am an out-of-network provider for other insurance companies, so if your policy covers out-of-network providers, you should be able to get some reimbursement. I can assist you in determining what your out-of-network coverage is and will provide you with a receipt with all necessary information to submit. In some cases, I may be able to submit the claim for you.


The client portal on my website is the best way to send electronic messages, as it is fully secure, unlike regular email services. It may take an extra step, but it ensures that these messages will not be accessed by anyone other than you and me.

Traditional email and text messages may be discovered and read by those who have access to your device as well as outside entities such as a wireless company. By signing this form, you acknowledge that you understand the confidentiality risks of email and text communication and that if you choose to communicate via these methods, you do so despite these risks.

Any communications may become part of your clinical record.

I check voicemail, texts and electronic messages regularly. When I am unable to do this, I will indicate it on my voicemail. If you need immediate assistance, please call the Thurston County crisis line at 360-586-2800.
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HIPAA Notice of Privacy Practices

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.


For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.

Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

Without Authorization. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.

As a social worker licensed in this state and as a member of the National Association of Social Workers, it is our practice to adhere to more stringent privacy requirements for disclosures without an authorization. The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPAA.

Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.

Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.

Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.

Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

Family Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

Health Oversight. If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.

Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.

Specialized Government Functions. We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.

Public Health. If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Research. PHI may only be disclosed after a special approval process or with your authorization.

Verbal Permission. We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.


You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to Stephanie Sisson.

• Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.
• Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.
• Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.
• Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.
• Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.
• Right to a Copy of this Notice. You have the right to a copy of this notice.


If you believe we have violated your privacy rights, you have the right to file a complaint in writing with me or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.

The effective date of this Notice is September 2013.
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