CLIENT DISCLOSURE INFORMATION - Washington State - dshs wa 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the AGENCY NAME as listed on the DASA certificate of approval. This ensures compliance with state regulations.
3. Fill in the COUNSELOR'S BUSINESS ADDRESS AND TELEPHONE NUMBER, matching the details from DASA's Directory of Certified Chemical Dependency Treatment Services.
4. Provide the WASHINGTON STATE REGISTRATION OR CERTIFICATION NUMBER for each counselor involved in your treatment, ensuring all current staff are listed.
5. List the NAME OF COUNSELOR and specify the TYPE OF COUNSELING they provide, including any specialties relevant to your treatment needs.
6. Detail THE METHODS AND TECHNIQUES THE COUNSELOR USES, such as individual or group counseling, to give clarity on what to expect during sessions.
7. Outline CLIENT'S COST PER EACH COUNSELING SESSION and any anticipated fees associated with your treatment plan.
8. Include a section on FEES PAID IN ADVANCE, explaining billing practices and refund policies clearly for transparency.
9. Ensure both you and your counselor sign the form after confirming that you have read and understood all provided information.

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