Dr. Roger Libby
Disclosure of Information and Client Agreement
Washington State law requires provision of the following information and written acknowledgment of its receipt. Please read and discuss as needed, and sign if you agree.
I offer sex and relationship therapy at a fee of $200. (50-60 minutes), which is payable by check or cash. There is a $20. charge for returned checks. I charge $200. for cancellations not made at least 48 hours in advance.
I am also available for phone and sometimes Skype sessions for those living too far away from my two offices. Please call 206-244-8788 to discuss phone sessions.
I utilize cognitive behavior therapy along with medical consultations when appropriate. The course of treatment varies by sexual and relationship problem, but all of my therapy deals with the connection between physical, mental and relationship realities.
As a therapy client, you have certain rights that are important for you to know. You have privileged communication under Washington state laws. You have the right to have information you share with me held in strict confidence. When I see a couple, I respect the confidentiality of each person. I will not repeat anything I am asked not to disclose. I follow federal guidelines to assure your privacy and confidentiality. Except for the following exceptions, I will not discuss you with anyone without your written permission.
1. Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report to appropriate authorities.
2. If a client is threatening serious bodily harm to another, I must notify the police and inform the intended victim.
3. If a client intends to harm him/herself, I will enlist their cooperation to ensure their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.
You have the right to choose a counselor who best suits your needs. If you at any time wish a referral to another counselor, I will help make such a referral.
I have an M.A. in Child Development and Family Relations, a Ph.D. in Sociology and a Post-Doctoral Fellowship in Family Violence. My focus through each of these degrees and experiences has been sexual behavior and marital and relationship issues. I am a Licensed Mental Health Counselor (LH 60106663) in Washington State, and I am board certified by The American Association of Sex Educators, Counselors and Therapists, The American Academy of Clinical Sexologists, The American Board of Sexology and The American College of Sexologists.
Please sign below and bring this form with you to your first session.