Mark A. Johnson, M.A.,
Licensed Marriage and Family Therapist

Welcome to my counseling practice. I look forward to being of service. In using the term “marriage and family”, I recognized the validity of a full range of couple and family units. Please take a moment to read through this Disclosure Statement and familiarize yourself with the policies of this practice. I encourage open communication between us and welcome your responses to any aspect of the therapy process. If you have any questions or concerns about what you read in these pages or what you experience in therapy, I hope you will share them with me.

Methods and Techniques ~
My work consists of individual, couple, family and group therapy. Although I incorporate a variety of different methods in my practice, my primary orientation is systemic. The basic assumption of a systems approach is that difficulties are viewed in the context of relationships, both past and present. The aim of the work is to help people change the relational patterns that perpetuate the difficulties and to enhance those patterns that are already proving beneficial.

Course of Treatment ~
We will work together in forming clear goals for the therapeutic relationship. These goals will be reviewed and/or revised together at least once every thirty days.

Education and Credentials ~
2000 ~ Master of Arts degree in Applied Behavioral Science with a concentration in Systems Counseling from Bastyr University’s School of Applied Behavioral Science (LIOS) Leadership Institute of Seattle
2003 ~ Certificate, U.S. facilitator training for Systemic Family Constellation Work.
2004 to current ~ Licensed Marriage and Family Therapist #LF00002142, Washington State

Session Starting Time ~
A standard 50 minute session will start at 10 minutes after the hour and run to the end of the hour. This lets you to think of your appointment time as beginning at the top of the hour while providing a grace period for unexpected delays. This allows you to run a little bit late and not miss any of your scheduled time. If you do arrive at the top of the hour, you will have the time to relax in the waiting room before your session. Please be sure you ask for clarification, if this is unclear.

Fees ~
The cost for each 50 minute counseling session is $125. You are responsible for paying the fee at the beginning or at the end of each session unless other arrangements are made. You may pay cash or by personal check. Personal checks may be held up to ten days upon your request. If you have insurance, I can work with you to maximize your benefits. However, you are ultimately responsible to pay whatever fees your insurance will not cover. Your clear understanding of the financial policy is important to our professional relationship. Please ask if you have any questions about fees or about your responsibility.

Cancellation or Rescheduling Policy ~
It is important that you make every effort to keep your scheduled appointments. You are welcome to cancel or reschedule appointments in order to meet your needs. However, when canceling or rescheduling an appointment, you must provide 24 hours notice or you will be charged my hourly fees. The cancellation fee will not be waived for reasons such as colds, car problems, lacking baby-sitting services, needing to work late at work, etcetera.

Confidentiality ~
Your identity, diagnosis and all issues discussed in the course of treatment are strictly confidential, written or verbal, with the following exceptions:

  • With the written authorization from you or, in the case of death or disability, your personal representative;
  • In response to a subpoena from the secretary. The secretary may subpoena only records related to a complaint or report under a regulatory investigation.
  • If you waive the privilege by bringing charges against this practice;
  • Instances where abuse of a child, elderly or disabled person is suspected.
  • To any individual if I reasonably believe that disclosure will avoid or minimize an imminent danger to the health or safety of the individual or any other individual; however, there is no obligation on the part of the provider to so disclose.

Competency ~
I understand that if I have questions about my treatment, my financial responsibilities, or aspects of the therapeutic relationship, I am encouraged to ask my therapist. Clients, as individuals, have the right to refuse treatment and to choose the practitioner and treatment modality that best suits their needs. Counselors practicing for a fee must be registered or licensed with the department of health for the public health and safety and to empower citizens of the state of Washington by providing a complaint process against those counselors who commit acts of unprofessional conduct. You may obtain a list or copy of the Acts of Unprofessional Conduct (RWC 18.130.180) by contacting: Health Professions Quality Assurance, Customer Service Center, PO Box 47865, Olympia, WA 98504 Email: hpqa.csc@doh.wa.gov Phone: 360-236-4700 Fax: 306-236-4818

Additional Contacts ~
If you should need to contact me outside of our scheduled time, you will be billed at my pro-rated hourly fee. Obvious exceptions to this policy include any contact required for scheduling, confirming or canceling appointments. Occasionally, I receive requests to release records to a physician, lawyer or other professionals. There will be no charge for a brief call to or from these professionals. If you request a written report or letter to be sent on your behalf, or if a lengthy conversation is necessary, I will charge my pro-rated hourly fee. If anything is unclear, please ask for clarification, before signing this form. By signing, I declare that I have read and agree to the above stated policies. I give my informed consent for services.

Client Signature: ­ ___________________________________________Date: _________________

Therapist Signature: ­ ______________________________________________________________

Mark A. Johnson, M.A. LMFT
6523 21 st Avenue NE, Suite 5B, Seattle, WA 98115-6924 Phone 206-525-0525