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Put on Letterhead Colville 99114 Chewelah 99109 Davenport 99122 Republic 99166 165 E. Hawthorne Ave. 301 E. Clay, #201 1211 Merriam St. 65 N. Keller. 509 684-4597 P.O. Box 905 509 725-3001 509 775-3341 1-866-708-4597 509 935-4808 1-888-725-3001 1-866-807-7131 Fax 509 684-5286 Fax 509 935-4897 Fax 509 725-1609 Fax 509 775-2937 Based at location checked above Counselor Disclosure Information (required by WAC 246-810-031) 1. Name and degree Tara Bates is an Agency Affiliated Mental Health Counselor (credential # CG60809298) with Northeast Washington Alliance Counseling Services (NEWACS). An agency affiliated counselor may only provide counseling services as part of his or her employment as an agency affiliated counselor for a ‘recognized agency.’ NEWACS is a ‘recognized agency.’ 2. Supervisor Information Tara’s direct supervisor is Theresa Brooks, LICSW, (License LW60146130). While working with Tara, you have the right to contact Theresa Brooks at any time to discuss your treatment or any concerns you may have regarding the services you receive through NEWACS. Theresa Brooks can be reached at (509) 684-4597 during regular office hours (8:00 am – 4:30 pm, Monday – Friday). 3. Education and Experience Tara received a Bachelor of Science degree in Psychology, with minors in Women and Gender Studies and in Philosophy, from Montana State University in 2012. She then earned a Masters in Counseling Psychology from Pacific University in 2014, with an educational focus on treating adults, and on Organizational Psychology. While receiving her Master’s degree, Tara completed a supervised clinical internship at the Native American Rehabilitation Association in Portland, OR, providing counseling services to a diverse population. She also worked as a youth advisor at a residential home for adolescent boys who were in the juvenile justice or foster care system. After receiving her Master’s degree, Tara worked at Lifeworks Northwest, a community mental health organization in Portland, OR, from early 2015 through the end of 2017, providing a variety of services including dual diagnosis evaluations and treatment recommendations for the community justice system of Multnomah County, providing individual and group therapies to adult populations, and working with LGBTQ persons on issues of identity resolution and transition. 4. Type of Services Provided Tara provides Individual and Group therapy for adults and children with mental illness and/or other emotional/behavioral problems (i.e. depression, anxiety, trauma, grief and loss). Tara does not prescribe medications. In the event that it is determined that medications might be an appropriate addition to your treatment, you will be referred to an appropriate medical provider. 5. Methods and Techniques Used Tara believes that treatment should be individualized and specific to the person seeking help, and to that end may utilize multiple modes and approaches to best meet your needs. Some modes of Client ID# Client Date: Printed Name: First Last Sec.6 12/17 Page 1 of 3 treatment she regularly uses include Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), Motivational Interviewing (MI), and insight-oriented talk therapy. CBT is a short-term psychotherapy that works to identify and solve current problems and change unhelpful thinking and behavior. CBT is "problem focused" (undertaken for specific problems) "action oriented" (therapist assists the client in selecting specific strategies to help address those problems), and directive in its therapeutic approach. DBT is a therapy designed to help people suffering from personality disorders. It has also been used to treat mood disorders as well as those who need to change patterns of behavior that are not helpful, such as self-harm, suicidal ideation, and substance abuse. DBT assumes that people are doing their best but lack the skills needed to succeed, and teaches specific skills such as interpersonal effectiveness or distress tolerance to change ineffective patterns. DBT may involve practice of skills between appointments, and group therapy. MI is a form of collaborative conversation for strengthening a person's own motivation and commitment to change. It is a person-centered counseling style for addressing the common problem of ambivalence about change by paying particular attention to the language of change. It is designed to strengthen an individual's motivation for and movement toward a specific goal by eliciting and exploring the person's own reasons for change within an atmosphere of acceptance and compassion. Tara may use a combination of these and other approaches to personalize your care, and also regularly uses measures such as the Patient Health Questionnaire (PHQ-9) to track your progress. All therapeutic approaches used are evidence-based, meaning they have undergone peer-reviewed validation of their effectiveness. Tara has additional experience and training working with the specific populations of LGBTQ-identified or questioning persons, polyamory or other non-traditional relationship styles, persons involved in the criminal justice system, persons diagnosed with personality disorders, and persons addressing issues of trauma and anxiety. 6. Course of Treatment Tara provides outpatient treatment services at NEWACS. These services usually start with a comprehensive assessment to determine your immediate needs. You and Tara will collaborate to develop an “Individualized Service Plan” (ISP) which will describe treatment modalities that you may receive. Treatment modalities may include case management and/or individual therapy with a focus on addressing your specific needs. Other professionals such as a Psychiatrist or Psychiatric Nurse Practitioner, Case Manager, Peer Counselor, your Primary Care Physician, and other “natural supports,” such as family and friends, may be included in the Treatment Team. This collaborative approach to treatment is designed to make available to you appropriate access to community resources that best fit your needs. The length of treatment is dependent primarily upon your needs and the presenting problem/diagnosis. Treatment can be as brief as 3-5 sessions, or as much as >150 sessions if this is deemed necessary. If you are enrolled in services for longer periods of time, your treatment plan will be reviewed every six months to determine the appropriateness of current goals and the need for continuation of services. Treatment services will come to an end when treatment goals have been met and/or you and/or your counselor determine that continuation is no longer desired or indicated. 7. Billing Practices You will have a financial interview to determine your responsibility to pay for services. At that time, you will sign an agreement which states what fee will be paid. Medical cards, Medicaid, Medicare, and private health insurance are accepted. 8. Counselor Credentialing Act Counselors practicing counseling for a fee must be registered or licensed with the Dept. 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. The purpose of the Counselor Credentialing Act 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 Page 2 of 3 process against those counselors who would commit acts of unprofessional conduct. You have the right to choose a counselor who best suits your needs and purposes. 9. Unprofessional Conduct You need to be informed there are acts that would be considered unprofessional conduct on behalf of your counselor. The Counseling or Hypnotherapy Clients brochure, which you were provided at the time of admission, includes a list of the kinds of behavior that would be considered unprofessional conduct and a violation of law as defined in RCW 18.130.180. If any acts of unprofessional conduct occur during your course of treatment, you are encouraged to contact the Department of Health to file a complaint against the offending counselor at the following address: Dept. of Health, Counselor Programs, P.O. Box 47869, Olympia, WA 98504-7869, (360) 236-4900. 10. Confidentiality & Acknowledgement I have been provided a copy of this Counselor Disclosure form and the brochure “Counseling or Hypnotherapy Clients” which includes information about the extent of confidentiality provided by RCW 18.19.180. I have read and understand the information provided. Client Signature Counselor Signature If signing for client, print name above & give relationship >>>Relationship to client (i.e., parent, foster parent, guardian, power of attorney, etc.) Date: Page 3 of 3 .
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