(1) Prior to conducting an assessment or providing any level of treatment, each direct service treatment staff must document in the participant's record that the participant was provided with the direct treatment staff's counselor disclosure which must include:

(a) The name of the direct service treatment staff;

(b) The name of the domestic violence intervention treatment program and the program's business address and telephone number;

(c) The direct service staff member's Washington state credential number;

(d) The direct service staff member's education, training, and experience;

(e) The direct service staff member's designation by the department as a trainee, staff, or supervisor;

(f) The name and description of the types of counseling or interventions provided by the direct service staff, including the treatment approach, methods, and techniques employed in their domestic violence intervention treatment program;

(g) Fee information, including:

(i) The cost for each assessment, group or individual counseling session;

(ii) Billing practices including any advance payments and refunds; and

(iii) A statement that participants are not liable for any fees or charges for services rendered prior to receipt of the disclosure statement;

(h) The limits of confidentiality under RCW 18.19.180;

(i) Disclosure of the direct service staff's supervisory or consultation agreement, including the supervisor's contact information, if they are not the program's supervisor or if they are receiving supervision from another practitioner;

(j) Disclosure that the direct service staff person is not credentialed to diagnose mental disorders or to conduct psychotherapy as defined in WAC 246-810-010(14) if it is outside their scope of practice;

(k) The following information regarding credentialed counselors:

(i) Counselors practicing counseling for a fee must be credentialed with the department of health for the protection of the public health and safety;

(ii) Credentialing of an individual with the department of health does not include a recognition of any practice standards, nor necessarily imply the effectiveness of any treatment;

(iii) The purpose of the Counselor Credentialing Act, chapter 18.19 RCW, which is to:

(A) Provide protection for public health and safety; and

(B) Empower the citizens of the state of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct; and

(iv) A reference of the acts of unprofessional conduct in RCW 18.130.180 and the name, address, and contact telephone number within the department of health for complaints; and

(l) Signature and date blocks for the direct service staff and participant, including an attestation that the participant has read, understands, and was provided with the required disclosure statement.