PROFESSIONAL DISCLOSURE STATEMENT & INFORMED CONSENT

Effective Date: June 3, 2026
Last Updated: November 1, 2026

VIBRANT LIFE COUNSELING, LLC

Jami Visaya, LMHC, LMFT
Licensed Mental Health Counselor — Washington License LH 60511285
Licensed Marriage & Family Therapist — Washington License LF 61441468

Business Address: 2520 S 118th St, Seattle, WA 98168
Phone: (206) 752-1904
Fax: (206) 758-4648
Email: info@avibrantlifecounseling.com
Website: www.avibrantlifecounseling.com

WELCOME & PURPOSE

This document serves as the Professional Disclosure Statement and Informed Consent for counseling services provided by Jami Visaya, LMHC, LMFT, through Vibrant Life Counseling, LLC.

Its purpose is to explain my professional qualifications, therapeutic approach, services, client rights, confidentiality practices, fees, and policies governing our professional relationship.

Please read this information carefully and ask questions about anything you do not understand. You have the right to receive information about your care, refuse treatment, and choose the provider and treatment approach that best meet your needs.

This disclosure is provided in accordance with Washington State requirements, including RCW 18.225.100 and WAC 246-809-700 and 246-809-710.

1. ABOUT YOUR THERAPIST

I am a bilingual (English/Spanish) Licensed Marriage and Family Therapist and Licensed Mental Health Counselor in Washington State and the owner of Vibrant Life Counseling, LLC.

I earned a Master of Science in Marriage and Family Therapy from St. Thomas University and a Bachelor of Arts in English, with minors in Psychology and Spanish, from Western Washington University.

My professional background includes more than 15 years of experience in educational and mental health settings serving diverse children, adolescents, adults, couples, and families. My professional counseling work began in 2014 at Sea Mar Behavioral Health, where I provided bilingual Spanish-English counseling services.

I provide counseling services through Vibrant Life Counseling, LLC. Services and appointment arrangements are discussed and confirmed before treatment begins.

Business Address Clarification: The Seattle address listed above is the business and administrative address of Vibrant Life Counseling, LLC. Counseling appointments are not held at this address. Any in-person appointment location will be separately confirmed when in-person services are available. Telehealth services are available to clients physically located in Washington State.

2. THERAPEUTIC APPROACH & METHODS

My approach is collaborative, compassionate, trauma-informed, culturally responsive, and inclusive. I provide multicultural counseling that recognizes how culture, ethnicity, identity, family history, intergenerational experiences, and broader social circumstances can shape relationships, emotional well-being, and personal experiences.

I work with individuals, couples, and families from diverse cultural backgrounds, including multicultural, multiracial, interracial, and multigenerational families. I strive to create a respectful, affirming, and nonjudgmental therapeutic environment where clients feel heard, understood, and valued.

Using a systemic and relational perspective, I help clients explore how their experiences, relationships, family patterns, and cultural backgrounds influence their current concerns. Together, we identify patterns, develop practical skills, and work toward meaningful change.

3. EDUCATION, TRAINING & PROFESSIONAL CREDENTIALS

Washington State Credentials

• Licensed Mental Health Counselor (LMHC), LH 60511285

• Licensed Marriage and Family Therapist (LMFT), LF 61441468

Education

• Master of Science in Marriage and Family Therapy, St. Thomas University

• Bachelor of Arts in English, with minors in Psychology and Spanish, Western Washington University

Additional Professional Background and Training

• Bilingual counseling in English and Spanish

• Multicultural and culturally responsive counseling

• Trauma-informed counseling approaches

• Inclusive and affirming therapeutic practices

• Family Systems and relational approaches

• Gottman Method Couples Therapy Level 1 Training

• Cognitive and behavioral approaches

I practice within the scope of my education, training, professional competence, and Washington State licensure requirements. When a client's needs fall outside my scope of practice or require a different level of care, I may recommend referral or additional services.

4. SERVICES OFFERED

Individual Counseling

Individual counseling supports clients in better understanding thoughts, emotions, behaviors, and relationship patterns while developing practical skills for meaningful change.

Areas commonly addressed may include:

• Anxiety and depression

• Stress, burnout, and life transitions

• Perfectionism and self-criticism

• ADHD-related concerns

• Sleep-related concerns

• Communication and relationship difficulties

• Self-esteem and self-worth

• Work-life balance

• Emotional regulation and coping strategies

• Unhelpful patterns and behaviors

Treatment is individualized according to each client's concerns, strengths, needs, and goals.

Couples & Family Counseling

Relational counseling may include services for:

• Couples and married partners

• Unmarried partners

• Families and multigenerational families

• Blended families

• Co-parents

• Other significant relationships, when clinically appropriate

Relational counseling focuses on communication, recurring conflict, emotional connection, trust, boundaries, family-of-origin experiences, and relationship patterns.

The goal is to help participants better understand the cycles that contribute to disconnection and develop healthier ways of relating.

Couples and family counseling may involve more than one participant. The structure of treatment, the identity of the client or clients, confidentiality expectations, and the applicable no-secrets policy will be discussed before relational treatment begins. Participants receiving relational services may also be asked to sign a separate Relational Therapy Addendum.

5. INSURANCE & PAYMENT ARRANGEMENTS

Individual Counseling

Individual counseling may be available through private pay or, when applicable and agreed upon, through an insurance-based arrangement administered through Headway.

When insurance is used, eligibility, benefits, copayments, deductibles, coinsurance, authorizations, and coverage limitations are determined by the insurance plan. Clients are responsible for understanding their insurance benefits and any amounts they owe.

Clients who do not wish to use insurance may discuss private-pay arrangements.

Couples & Family Counseling

Couples and family counseling through Vibrant Life Counseling, LLC is offered as a private-pay service. Insurance is not billed for relational counseling.

Insurance plans may have specific requirements for reimbursement, including a designated individual patient and a covered diagnosis. These requirements may not reflect the goals or structure of relationship-focused counseling.

For private-pay services, a Good Faith Estimate is provided when required under applicable law. Clients may request a Good Faith Estimate before scheduling or receiving services.

Superbills may be available for eligible private-pay services upon request. A superbill does not guarantee reimbursement. Clients are responsible for checking their own out-of-network benefits.

6. NATURE, BENEFITS & RISKS OF COUNSELING

Counseling is a collaborative process intended to support self-understanding, emotional well-being, personal growth, and meaningful change.

Treatment goals may include:

• Increasing self-awareness and understanding

• Improving emotional regulation

• Identifying and changing unhelpful patterns

• Strengthening relationships and communication

• Developing effective coping skills

• Improving conflict resolution

• Building healthier boundaries

• Addressing concerns related to family, culture, identity, and life experiences

Counseling may involve discussing difficult or painful experiences. You may experience uncomfortable emotions, increased awareness of relationship difficulties, or temporary distress as part of the process.

Potential benefits include improved insight, coping skills, communication, emotional well-being, and relationships. However, no particular outcome or timeline can be guaranteed.

Treatment goals and progress will be reviewed periodically. The course and length of treatment depend on your needs, circumstances, preferences, and progress.

7. TELEHEALTH SERVICES

Telehealth counseling is provided through secure video conferencing platforms appropriate for the services being delivered.

Clients receiving telehealth services must:

• Be physically located in Washington State during sessions.

• Participate from a private location whenever possible.

• Have a reliable internet connection and appropriate device.

• Provide accurate location and emergency contact information.

• Avoid participating while driving or in circumstances that compromise safety or privacy.

Telehealth offers flexibility and accessibility but has limitations. Technology may fail, internet connections may be interrupted, and privacy cannot be guaranteed in every environment.

If a technical problem interrupts a session, we will make reasonable efforts to reconnect or arrange another time. If a safety concern or emergency arises, emergency procedures may be necessary.

Telehealth is not a substitute for emergency or crisis services.

8. CONFIDENTIALITY & ITS LIMITATIONS

Information shared in counseling is confidential and protected under applicable Washington State and federal privacy laws, including HIPAA when applicable.

Information will not ordinarily be disclosed without appropriate authorization except when disclosure is required or permitted by law.

Situations that may require or permit disclosure include:

• When there is a legally recognized duty to protect or respond to a serious and imminent safety concern.

• When reporting suspected child abuse or neglect as required by law.

• When reporting suspected abuse, neglect, or exploitation of a vulnerable adult as required by law.

• When disclosure is otherwise required or permitted under applicable Washington law.

• When disclosure is authorized by a valid written release.

• When disclosure is permitted for healthcare operations, payment, or other purposes allowed by law.

• When responding to applicable legal process, court orders, or other lawful requirements.

• When information is requested by an authorized licensing or regulatory authority within its lawful authority.

A subpoena or other legal request will be reviewed in accordance with applicable law. A subpoena alone does not necessarily mean that confidential information may be released.

Confidentiality protections and exceptions may differ depending on the type of service, the participants involved, and applicable law. I will make reasonable efforts to explain relevant confidentiality considerations before treatment begins.

HIPAA Notice of Privacy Practices: The separate Notice of Privacy Practices provides additional information about how protected health information may be used and disclosed and how clients may exercise their privacy rights. It is provided separately as part of the client intake process.

9. COUPLES & FAMILY COUNSELING — NO-SECRETS POLICY

Relational counseling has confidentiality considerations that differ from individual counseling.

For couples and family work, the treatment focus is the relationship or family system rather than automatically treating each participant as an individual therapy client.

Vibrant Life Counseling, LLC maintains a no-secrets policy for relational counseling. Information shared individually with the therapist that is relevant to the relationship or treatment may be brought into the relational therapy process. This may include information that affects trust, safety, relationship decisions, or the goals of treatment.

The policy is intended to support transparency and meaningful therapeutic work. It is not a promise that every individual disclosure will automatically be shared in every circumstance. The application of the policy, including how individual meetings and disclosures are handled, will be discussed before treatment.

All participants in relational counseling must understand and agree to the applicable confidentiality expectations. A separate Relational Therapy Addendum may provide additional details and requires acknowledgment by the applicable participants.

10. RECORDS & DOCUMENTATION

Clinical records are maintained in an electronic health record system with safeguards intended to protect client information.

Records may include intake information, consent forms, treatment plans, progress notes, billing information, and other documentation relevant to care.

Records are retained for at least seven (7) years following the last date of service, subject to applicable legal and professional requirements.

Clients may request access to or copies of their records as permitted by law. Requests for records, corrections, or other documentation should be submitted through the appropriate secure process.

11. ELECTRONIC COMMUNICATION & PRIVACY

Electronic communication may be used for scheduling, billing, appointment reminders, and other administrative matters.

Communication methods may include:

• Secure client portal messaging

• Email for appropriate administrative communication

• Voicemail

• Appointment and scheduling notifications

Text messaging is not used for clinical communication.

Please do not send sensitive clinical information through ordinary email, text messages, or website contact forms. Use the secure client portal for clinical information and documents.

Although reasonable safeguards are used, electronic communications may carry privacy and security risks. Electronic messages are not monitored continuously and should never be used for emergencies.

12. PROFESSIONAL BOUNDARIES

Counseling is a professional relationship with clear boundaries intended to protect clients and maintain appropriate therapeutic care.

To support those boundaries:

• I do not connect with current clients through personal social media accounts.

• Communication outside sessions is limited to appropriate professional matters.

• I do not initiate contact with clients if we encounter one another in public, in order to protect client confidentiality. You may acknowledge me if you choose.

• Dual relationships are avoided when possible and addressed in accordance with professional and ethical standards.

13. FEES & FINANCIAL POLICY

The following are the current standard fees for services through Vibrant Life Counseling, LLC:

Individual Counseling

• 60-minute session: $150

Couples & Family Counseling

• 60-minute session: $200

• 90-minute session: $300

• Three-hour couples intensive: $800

The appropriate session length and fee will be discussed before scheduling.

Fees may be updated with advance notice. Any fee changes applicable to ongoing services will be communicated before they take effect.

Payment

Payment is due at the time of service unless another arrangement has been agreed upon in writing.

A valid payment method may be required to be maintained on file. When authorized, the payment method on file may be charged for services provided, late cancellations, missed appointments, and outstanding balances in accordance with the applicable financial agreement.

Advance Payments & Refunds

Any advance payment, deposit, or prepaid service will be explained before payment is collected. Payments for services already provided and disclosed fees that have been properly incurred are not refundable. If an advance payment exceeds the amount owed for services provided or fees properly incurred, the unused balance will be refunded.

Clients may ask questions about charges, payment arrangements, or financial responsibilities before agreeing to services.

Good Faith Estimates

Under the No Surprises Act, eligible uninsured or self-pay clients may receive a Good Faith Estimate of expected charges. The estimate is based on the services reasonably expected at the time it is prepared. Actual services and costs may change depending on treatment needs and client preferences.

14. CANCELLATION & ATTENDANCE POLICY

Appointment times are reserved specifically for each client or relational therapy appointment.

At least 24 hours' notice is required to cancel or reschedule an appointment.

Appointments canceled with less than 24 hours' notice, or missed without notice, may be charged the full scheduled session fee:

• Individual 60-minute session: $150

• Couples/family 60-minute session: $200

• Couples/family 90-minute session: $300

• Three-hour couples intensive: $800

Insurance does not generally cover missed appointments or late-cancellation fees.

Emergency circumstances may be reviewed on a case-by-case basis. Repeated missed appointments, late cancellations, or attendance concerns may result in a review of whether ongoing services are appropriate.

15. CRISIS & BETWEEN-SESSION SUPPORT

Vibrant Life Counseling, LLC does not provide 24-hour crisis services or continuous monitoring of messages between sessions.

Messages are generally returned within one to two business days during regular business hours. Response times may vary.

If you are experiencing an emergency or believe you may be at immediate risk of harming yourself or someone else:

• Call 911 or go to the nearest emergency department.

• Call or text 988 for the Suicide & Crisis Lifeline.

• For King County crisis support, call 866-427-4747.

• You may also text HOME to 741741 for the Crisis Text Line.

Do not use email, voicemail, text messages, or the client portal for emergency assistance.

16. COURT-RELATED & FORENSIC SERVICES

Vibrant Life Counseling, LLC provides counseling services and does not provide the following services:

• Child custody evaluations

• Parenting evaluations

• Forensic psychological assessments

• Court-ordered treatment

• Expert witness services

Participation in legal proceedings, preparation of forensic opinions, or evaluations for litigation is outside the scope of services offered through this practice.

17. DISCHARGE & TRANSFER OF CARE

Clients may choose to end counseling at any time.

When appropriate, we may discuss the decision to end treatment and consider referrals or other resources to support continuity of care.

Treatment may also be concluded or transferred when:

• Treatment goals have been met or continued treatment is no longer clinically indicated.

• A client's needs require a higher level of care.

• A client's needs fall outside my professional scope, training, or competence.

• Repeated missed appointments or attendance concerns interfere with treatment.

• Financial responsibilities remain unresolved.

• Other circumstances make continued treatment inappropriate or impractical.

When appropriate, referrals to qualified providers or additional resources will be offered.

Clients may request treatment summaries or copies of records in accordance with applicable law.

18. CLIENT RIGHTS & RESPONSIBILITIES

You have the right to:

• Receive respectful, ethical, inclusive, affirming, and culturally responsive care that recognizes and respects your individual differences, identities, cultural backgrounds, and lived experiences.

• Receive information about my professional qualifications, education, training, and therapeutic approach.

• Ask questions about treatment, fees, and practice policies.

• Participate in developing and reviewing your treatment goals.

• Be informed about the potential benefits, risks, and limitations of counseling.

• Receive confidentiality and privacy protections under applicable law.

• Request access to your records as permitted by law.

• Request corrections to records when appropriate.

• Refuse treatment or decline a recommendation.

• Choose a practitioner and treatment approach that best meet your needs.

• Discontinue services at any time.

• File a complaint with the appropriate licensing authority.

Clients are responsible for:

• Providing accurate information relevant to treatment.

• Participating in treatment decisions and communicating questions or concerns.

• Attending scheduled appointments or providing appropriate cancellation notice.

• Maintaining privacy during telehealth sessions.

• Using appropriate communication channels.

• Meeting agreed-upon financial responsibilities.

• Seeking emergency or crisis services when needed.

19. QUESTIONS, CONCERNS & COMPLAINTS

Questions or concerns about treatment are welcome. Whenever possible, I encourage clients to discuss concerns directly with me so we can work toward a resolution.

Clients also have the right to contact the Washington State Department of Health to ask questions or file a complaint about a licensed healthcare professional.

Vibrant Life Counseling, LLC
Jami Visaya, LMHC, LMFT
Phone: (206) 752-1904
Email: info@avibrantlifecounseling.com

Washington State Department of Health
Health Systems Quality Assurance
Complaint Intake Unit
P.O. Box 47857
Olympia, WA 98504-7857
Phone: 360-236-2620
Email: hsqacomplaintintake@doh.wa.gov
Website: https://doh.wa.gov

U.S. Department of Health & Human Services — Office for Civil Rights
Phone: 1-800-368-1019
Website: https://www.hhs.gov/hipaa/filing-a-complaint

20. ACKNOWLEDGMENT & CONSENT FOR TREATMENT

By signing this document, I acknowledge that:

• I have received and reviewed the Professional Disclosure Statement & Informed Consent.

• I have had the opportunity to ask questions and receive answers.

• I understand the therapist's professional qualifications, education, training, and therapeutic approaches.

• I understand the nature, potential benefits, risks, and limitations of counseling.

• I have been informed of confidentiality and its legal limitations.

• I understand the fees, payment arrangements, cancellation policy, and financial responsibilities applicable to my services.

• I understand that I may refuse treatment, decline recommendations, or discontinue services.

• I understand that telehealth is not an emergency service and that emergency resources must be used when necessary.

• I understand that additional documents may apply to my services, including the HIPAA Notice of Privacy Practices, Good Faith Estimate, financial agreement, and Relational Therapy Addendum when applicable.

• I have had the opportunity to ask questions and voluntarily consent to participate in counseling services with Jami Visaya, LMHC, LMFT, through Vibrant Life Counseling, LLC.

Client acknowledgment: My signature confirms that I have been provided a copy of this disclosure, have read and understand the information provided, and have had the opportunity to ask questions.

Client Name: ______________________________________

Client Signature: ___________________________________

Date: _____________________________________________

Additional Client/Participant Name, if applicable: __________________________

Additional Client/Participant Signature: _________________________________

Date: _____________________________________________

Licensee: Jami Visaya, LMHC, LMFT

Licensee Signature: __________________________________

Date: _____________________________________________

Vibrant Life Counseling, LLC
Relationship-focused counseling for couples, families, and individuals.