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Michaela Phillips
In Bloom Integrative Therapy

522 Riverside Ave Ste N, Spokane, WA 99201

InBloomIntegrativeTherapy.com

501-453-0571, Michaela@inbloomintegrativetherapy.com

Independent Practice

I am an independently contracted provider participating in the Mindful Therapy Group Organized Health Care Arrangement (OHCA). While I have engaged Mindful Therapy Group, P.C., a Washington Professional Services Corporation (Mindful Therapy Group), to provide business administrative services to my behavioral healthcare business, all services you receive from me reflect my own health care license, independent business, and practice style. Mindful Therapy Group subcontracts with an affiliate company, Mindful Support Services, LLC (Mindful Support Services), to provide a portion of the administrative services.

My License(s), Education and Training

I hold the following license(s) in the indicated state(s): Washington SC70072833

I hold an MSW from the University of Missouri, Columbia and currently hold a Social Work Associate Independent Clinical license, trained under to National Association of Social Work Code of Ethics. As a licensed clinician, I am required to participate in continuing education.

I participate in regular supervision with LICSW and Mindful Therapy Group therapist, Valaree Schelhammer. 

Additional information about my licensure is available on the Department of Health’s website, under “Provider Credential Search” at https//fortress.wa.gov/providercredentialsearch/.

Patient Mix

I offer therapy services for individuals. I see clients 18 and older. I do not offer case management services, which includes but is not limited to providing paperwork for disability, unemployment, custody, adoption, foster care, car accidents, and any type of legal issues. I do offer therapy for individuals who are court mandated for treatment or seeking treatment in which disclosure of appointments will need to be provided to an outside entity.

Treatment Modality and Therapeutic Orientation

My clinical approach is integrative, trauma-informed, and client-centered. I draw from evidence-based modalities including Cognitive Behavioral Therapy (CBT), mindfulness-based interventions, strengths-based practice, attachment-based approaches, and somatic-informed techniques, tailoring treatment to the unique needs, developmental stage, and goals of each client. My work is grounded in a relational framework and emphasizes emotional safety, nervous system regulation, and collaborative goal setting.

Therapy has both benefits and risks. During the course of therapy, you might notice changes in your symptoms, problems, and functioning. Since we will be exploring challenging territory in your life, you might experience greater difficulty throughout our work. Therapy typically produces benefits over time, but sometimes as you get to the root of tender issues, you may feel them even more acutely than in the past. I cannot offer any promise or guarantee about the results you will experience. However, as you commit yourself to work through your vulnerable issues and build upon your strengths, it is likely that you will see improvements throughout our work and in the future.

New Patients

There will be 1-2 initial visits to ensure proper assessment and thorough evaluation. Appointment(s) are 55 minutes. These appointments will be used to evaluate, educate, and determine a mental health diagnosis. I may want to see you weekly until either your symptoms are alleviated, or your condition is stabilizing. We will work together to determine the best frequency of appointments going forward based on your health, treatment goals, and stability of your condition.

Cancelling Appointments

In order to provide you with optimal care, your appointment time is reserved specifically for you. I do not double book clients. In return, I ask that you provide our front office with a minimum of 24 hours’ notice if you are unable to make it to your appointment. Please call our front office staff for all scheduling needs at (425) 640-7009 to ensure prompt attention.

I work with all my clients on a recurring, weekly basis. If you cancel several appointments, I will ask that you be removed from your recurring appointment slot and be placed on my on-call list, as repeated cancellations present a barrier to the therapeutic process. If you are on the on-call list, I will reach out to you as appointments become available. If you have repeated no-show appointments, upcoming scheduled appointments may be cancelled.

Requests for Consultation

If you need a consultation outside of a scheduled appointment, please direct your request to me via the email or phone number listed. Mindful Therapy Group administrative staff are not clinically trained and are unable to respond to requests for consultation.

In general, my office hours are Fridays from 2 PM to 8 PM and Sundays from 8 AM to 6 PM. I may not be able to respond to requests for consultation outside of these hours.

Emergencies

I am not available on an emergency basis. If you are experiencing an emergency or are concerned you may be a threat to yourself or others, please dial 911, 988 (an emergency line specific to suicide and mental health crises) or go to the nearest hospital emergency room.

Contact for Administrative/Scheduling Questions

If you have questions about scheduling, billing or technology, please contact Mindful Therapy Group at:

frontdesk.wa@mindfulsupportservices.com
scheduling.wa@mindfulsupportservices.com

425-640-7009

7:00am-7:30pm Monday-Friday
8:00am-4:00pm Saturday-Sunday

Rescheduling Appointments

Mindful Therapy Group and/or I will make every effort to provide you with adequate notice if I will be unavailable for a scheduled appointment.

If you need to reschedule an appointment, the rescheduling request should be made with Mindful Therapy Group, not me. If you need to reschedule an appointment, I ask that you give Mindful Therapy Group at least 24 hours’ notice in advance of the originally scheduled appointment. Rescheduling requests made without 24 hours’ advance notice will incur late cancellation fees (see Financial Responsibility section below).

Confidentiality

All information disclosed within appointments is confidential. I keep brief notes of our appointments, but such notes and other information related to these appointments will not be disclosed to anyone except as permitted or required by law.

Notice of Privacy Practices

The Mindful Therapy Group Organized Health Care Arrangement Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can get access to this information. An electronic copy of the Notice of Privacy Practices can be found here.

Your Rights

You have the following rights:

-       To refuse treatment;

-       To choose a practitioner and treatment modality which best suits your needs;

-       To expect that I have met the qualifications of training and experience required by state law;

-       To examine public records maintained by the state authority that licenses me and to have such authority confirm my credentials;

-       To obtain a copy of the code of ethics to which I am bound;

-       To report complaints to the state authority that licenses me:

Washington State Department of Health - Health Systems Quality Assurance (HSQA)
Complaint Intake
PO Box 47857
Olympia, WA 98504-7857
Phone: (360) 236-4700
Email: hsqa.complaints@doh.wa.gov
Website: https://fortress.wa.gov/doh/providercredentialsearch/ComplaintIntakeForm.aspx

-       To be informed of the cost of my services before receiving the services;

-       To be assured of privacy and confidentiality while receiving services from me (note - the law sometimes permits or requires disclosures of private/confidential information); and

-       To be free from free from discrimination because of age, color, culture, disability, ethnicity, national origin, gender, race, religion, sexual orientation, marital status, or socioeconomic status.

 TELEHEALTH CONSENT

As a client of Mindful Therapy Group, I acknowledge that I will have the opportunity, but not the obligation, to utilize a video conferencing platform (i.e. Telehealth) for sessions with my provider. Using Telehealth is at the mutual discretion of my provider and I.

·       In utilizing Telehealth, I agree to participate in technology-based sessions with my Provider, and I authorize information related to my health to be electronically transmitted in the form of images and data through an interactive video connection to and from my Provider and other persons involved in my health care.

·       I represent that I am using my own equipment to communicate and not equipment owned by another and am specifically not using my employer’s computer or network. I am aware that any information I enter into an employer’s computer can be considered by the courts to belong to my employer and my privacy may thus be compromised.

·       I have read this document carefully and fully understand the benefits and risks. I have had the opportunity to ask any questions I have and have received satisfactory answers. With this knowledge, I voluntarily consent to participate in Telehealth sessions, including, but not limited to, care, treatment, and services deemed necessary and advisable, under the terms described herein.

Patient Name:                                                                                                                                   

Patient Date of Birth:                                                                                                                       

* If patient is under the age of 18 the patient’s parent or legal guardian must sign below unless a minor patient is requesting to be assessed as a mature minor in accordance with state eligibility guidelines

Signed:                                                                                                                                                

Name:                                                                                                                                                 

Relationship to Patient (e.g., self, parent):                                                                                        

 ARTIFICIAL INTELLIGENCE 

Artificial Intelligence (AI) tools may be integrated into your sessions to complement the therapeutic process. Your privacy and confidentiality while utilizing AI tools are of utmost importance. Any data inputted into AI tools will be securely stored according to HIPAA privacy guidelines.

I have read and understood the above information and consent to the utilization of AI to support the therapeutic process. I understand that my consent is voluntary, and I have the right to withdraw my consent at any time.

Patient Name:                                                                                                                                    

Patient Date of Birth:                                                                                                                       

* If patient is under the age of 18 the patient’s parent or legal guardian must sign below unless a minor patient is requesting to be assessed as a mature minor in accordance with state eligibility guidelines.

Signed:                                                                                                                                               

Name:                                                                                                                                                 

Relationship to Patient (e.g., self, parent):                                                                                         

Financial Responsibility

Insurance Fees

I am in-network with a select number of insurance companies for my services. Please provide full insurance information and your insurance card upon your initial visit (or before, if possible) so we can determine the benefits for which you are eligible. If you have a change in insurance, please let us know as soon as possible.

Your insurance plan may require me to assess you a copayment, coinsurance or deductible (“cost share”). Mental health appointments are assigned billing codes on claims that vary based on factors such as appointment length and complexity. As a result, your cost share may vary from visit to visit. 

Any cost share is due at the time of service. Mindful Therapy Group staff and I will do our best to estimate your cost share in advance of or at the time of your appointment. However, it is possible that your insurance plan, after reviewing the claim, will determine that your cost share is higher than we estimated. In these situations, Mindful Therapy Group will notify you about any balance due with a monthly statement. In the event we overestimate the cost share, the credit will be applied towards your future visits, unless you specify otherwise.

If your insurance plan requires preauthorization for services, it is your responsibility to obtain this authorization prior to our appointment. If you fail to obtain authorization, any and all charges incurred for services rendered by me and not reimbursed to me or Mindful Therapy Group by your health insurance will be your financial responsibility.

Private Pay (Self-Pay) Fees

·       $110 per 55-minute session for individuals

Case Management Time Fee

Most clinical issues should be shared in our appointment. If calls and case management become excessive, I may need to charge for case management time. I will always inform you prior to providing this service and prior to billing for it.

·       $110 per hour.

Cancellation Fees

If you are unable to provide more than 24 hours’ notice, you will incur a missed appointment/late cancellation fee as follows:

·       $110 for missing session

This charge is irrespective of the reason for the cancellation/no show. Insurance does NOT cover this fee and will automatically be charged to the credit card listed on file.

While I understand unexpected things sometimes pop up, if there is a pattern noticed of cancelled appointments, I may be unable to continue providing services to you, and I reserve the right to cancel future appointments in order to make room for clients committed to the therapeutic process. I will always communicate about this with you and determine if we’re a good fit prior to making changes to your scheduled appointments.

Washington Apple Health (Medicaid) Billing

In accordance with WAC 182-502-0160, if you are using Washington Apple Health (Medicaid) to cover services, I may not bill you for the following:

·       Services covered under your Apple Health plan, even if I have not yet been paid.

·       Services denied because of provider error (such as missing prior authorization or required documentation).

·       Missed, canceled, or late appointments.

You may only be billed for services that Apple Health does not cover if you sign an “Agreement to Pay for Healthcare Services” before receiving those services. If Mindful Therapy Group is not contracted with your Apple Health plan, you may be responsible for fees and any cost-sharing as determined by your plan.

For more details, please refer to your Apple Health plan documents or applicable Washington regulations.

Collections

If you have an unpaid patient balance of $110 for more than 120 days, the balance may be turned over to a third-party collections’ agency. You will receive a final courtesy phone call and/or letter to remind you of your balance due. If you believe that there is an error in your billing, please let us know as soon as possible so we can research the issue. Unpaid balances without a payment plan or partial payment initiated after 120 days will initiate a phone collections effort for recovery, and some identifying confidential information will be released in this process. This may negatively impact your credit. It is very important that you update your contact information with us to ensure you are aware of your financial responsibility and receive your statements.

Assignment of Benefits

In exchange for, and in connection with, any and all of the services provided to you or your child, as applicable, by your Provider, you irrevocably assign and transfer to Mindful Therapy Group and your Provider all of the rights, benefits, privileges, protections, claims and any other interests of any kind whatsoever, without limitation, that you or your child, as applicable, had, have or may have in the future pursuant to or in connection with any health insurance policy or plan, health benefit plan, health management agreement, healthcare risk-bearing agreement, healthcare trust, healthcare fund or any other source of payment, healthcare insurance, healthcare indemnity or health or medical coverage of any kind covering you or your child, as applicable to healthcare. This assignment also includes assignment of your or your child’s, as applicable, appeal rights, fiduciary rights, rights to sue, rights to payment, rights to full and fair claims review, rights to penalties or interest, rights to plan documents and plan information, and rights to notices and disclosures from any source.

Patient Name:                                                                                                                                   

Patient Date of Birth:                                                                                                                       

* If patient is under the age of 18 the patient’s parent or legal guardian must sign below unless a minor patient is requesting to be assessed as a mature minor in accordance with state eligibility guidelines

Signed:                                                                                                                                               

Name:                                                                                                                                                 

Relationship to Patient (e.g., self, parent):