Disclosure Statement required by Washington State for mental health treatment only.
(Not required for the self-help educational instruction discussed on this website – I am not accepting new clients at this time).
Name of Counselor’s Practice: George Smith, M.A.
Business telephone number: (360) 459-0811
Business address: Box 14613, Tumwater, WA 98511
Counselor’s name: George Smith, M.A.
Type of counseling: State Licensed Mental Health Counseling
License number: LH00004380
Methods or techniques used: Eclectic approach primarily based on Rational Emotive Behavior Therapy (REBT).
Counselor’s education: Masters degree in Counseling Psychology, Ball State University, Muncie, Indiana, 1974. Postgraduate independent research, The Evergreen State College, Olympia, Washington, 1979.
Counselor’s experience: Private practice; former therapist, Western State Hospital; former state-designated Mental Health Professional (MHP); former county Superior Court Probation Counselor.
Client’s cost per session: private sessions are $25 each for each 5 minute segment. All fees are nonrefundable. In the event of an emergency cancellation, one rescheduling will be offered at no additional charge.
“A person licensed under this chapter must provide clients at the commencement of any program of treatment with accurate disclosure information concerning the practice, in accordance with rules adopted by the department, including the right of clients to refuse treatment, the responsibility of clients to choose the provider and treatment modality which best suits their needs, and the extent of confidentiality provided by this chapter. The disclosure information must also include the license holder’s professional education and training, the therapeutic orientation of the practice, the proposed course of treatment where known, financial requirements, and such other information as required by rule. The disclosure must be acknowledged in writing by the client and license holder.” – RCW 18.225.100 Disclosure information.
Before I can begin a mental health treatment program with you, you must sign the following statement and return it to me.
/ George Smith, M.A. /
I acknowledge that I have read and fully understand the above disclosure information required by law. I also acknowledge that I have been provided with, have read and fully understand the information brochure “What to Expect from your Licensed Mental Health Counselors (LMHC)” published by the State of Washington, Department of Health that was provided for me by the counselor. I understand that my copy of this document constitutes my legal receipt of disclosure information.
_________________________________ ____________________________
Your signature Today’s date
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Your complete email address
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Please print your name, complete telephone number, and the best times to call.
Credit or Debit card number:____________________________________exp date______
Three digit security code on back of card : _____
or enclose pre-payment with this form.