Questions about what it’s like to work together?

I’m physically located in Tacoma, Washington but can provide online therapy to anyone in Washington, Utah or Florida.

Yes, I see clients for weekly and biweekly therapy appointments in person at my office in Tacoma at 4041 Ruston Way Suite 202, Tacoma, WA 98407. I also see couples for therapy intensives at my office on the weekends.

45 minute Individual Session: $200

75 minute Individual Intake Session: $300

75 minute Couple/Family Session: $375

105 minute Couple/Family Session: $500

105 minute Individual Intake Session: $500

I provide limited openings with sliding scale options for clients facing financial constraints. Payments will be collected at the start of the session.

I am an out of network provider for some therapy services. All services are paid upfront.

• For individual therapy, if you would like to cover it with your out of network benefits (OON), I will send you a superbill, which is summary of the treatment you got and what you paid for, at the end of the month, with a mental health disorder diagnosis, if your symptoms meet the criteria for a diagnosis. Mental health treatment is only considered medically necessary and thus covered by your insurance if your symptoms are severe enough to warrant a diagnosis. Many people who don’t meet diagnostic criteria for a mental health diagnosis benefit from therapy. In this case, your therapy will be out of pocket. To fake a diagnosis is insurance fraud.

• Couple/family therapy may be able to be covered by your OON benefits. You can ask your insurance if they reimburse for the diagnostic code Z63.0–“Relational Distress” and the CPT code 90847–“Family therapy with the patient present”. The diagnostic code is the relational diagnosis, what I’m treating, and the CPT code is the service code, describing how I’m treating what you’re struggling with (services rendered). You must verify both of these with your insurance to ensure that you get the reimbursement you expect. Simply hearing from your insurance that they cover couple or family therapy does not mean that they will reimburse for the diagnosis and service which will be on the superbill that I send you. I want to make sure that you’re not left with unexpected bills or that this causes a disruption in your treatment.

• For couple therapy intensives, it is likely you will only be reimbursed for one hour of each day we meet. Most insurance companies don’t cover longer sessions or multiple hours of therapy in one day.

• The healthcare model as it exists typically does not cover therapy where the relationship is the client, only individuals with mental health diagnoses seeking care with or without an adjunct person in the room. Healthcare for relationship diagnoses is not considered medically necessary by many health insurance companies and thus may not be covered by your insurance. You are always responsible for inquiring about your coverage and for paying bills upfront, at the time of service.

• For those who choose to use their insurance for out of network coverage, their diagnosis will be a part of their permanent medical record and may adversely affect future life decisions, like the desire to be in the armed forces, and their treatment will not be confidential from insurance companies, who may request records.

I also used to send superbills for couples therapy diagnosing one individual in a couple. After consulting with a lawyer, I decided to discontinue this practice due to several reasons. As is explained above under the insurance tab, couple or family therapy as I practice it (and as many couple and family therapists practice it) is not covered by your insurance. I treat the relationship and the relationship is my client, meaning that my interventions are all working towards the goal of a healthier relationship for you. This sometimes means that I work with one or both partners on mental health issues, however, our therapy goals, treatment plan and notes are all written and framed in the context of your relationship. Your personal symptoms of distress, like anxiety or depression, resulting from your relationship conflict or disconnection will be helped and resolved in the course of relationship therapy, if the cause of your mental distress is due to your relationship struggles. Relationship therapy does help individuals with mental health diagnoses. It’s unfortunate that insurance companies do not see the benefit of relationship therapists and do not view relationship diagnoses as medically necessary.

The most common way relationship therapy is covered by insurance (INN or OON) is because it is coded with the CPT code 90847–“Family therapy with the patient present”. Your couple therapist most likely gave one of you a mental health diagnosis, like F41.1 Generalized Anxiety Disorder, and billed sessions to that person’s insurance. This means that one of you is the Identified Patient (IP), and is considered the patient in therapy, rather than the relationship or both people being the patient. This impacts your therapy in the following ways:

• The IP has a mental health diagnosis on their permanent medical record, given to them by the couples therapist.

• The IP is the only one who has access to the medical records for the treatment, meaning that if you and your partner go to court for any reason and request records of the therapy, only the IP has full access to these medical records. The IP’s partner is considered adjunct to therapy and does not have rights to the patient’s treatment record.

• Because it is the IP’s therapy and that person is being treated for their mental health diagnosis, they could at any point ask their partner to leave the therapy room or to not attend an appointment, because it is technically their therapy. This means that the two of you are on unequal footing in treatment.

• Therapy may be insurance fraud if the therapist has “fudged” the diagnosis in order to get your treatment covered by insurance or does one thing in therapy (interventions focused on treating the relationship) and reports doing another in their therapy notes (interventions focused on treating the IP’s mental health diagnosis) in order to make sure your treatment is covered by insurance.

In addition to the above issues, insurance reimburses relationship therapy at a lower rate than individual therapy. INN therapists struggle to make a living wage, regardless of the CPT codes they bill insurance for. Couples therapy is considered by many the hardest specialty in therapy and requires additional training beyond graduate school just to begin to see couples in therapy. Insurance rates do not pay therapists, especially couple therapists, the wages they need to continue learning, growing and practicing this difficult and challenging work.

Click here to view my online calendar and schedule an intake appointment. Your first appointment will be longer (1.5-2 hours) so that we can discuss what you would like help with in therapy and you can get a feel for what therapy feels like with me. The best way to determine fit is to do trial therapy. You will get help immediately and be able to decide if it's right for you. Please make sure my openings work with you for ongoing therapy.

I have a strict 48 hour cancellation policy–no exceptions or “freebies”. You must cancel or change your appointment at least 48 hours before the scheduled time. After that, you will be unable to cancel or reschedule and will be charged for the appointment. Appointments are canceled and scheduled in your client portal. An appointment will not be considered canceled unless it is done in your client portal–voicemails, texts or emails will not count as cancellations.

For ongoing couples therapy, I meet with both partners together. Since my client is the relationship, I always see the relationship for therapy, with the exception of couples with a past or current history with IPV/DV, for which I do 1:1 assessments before beginning couples therapy. For couples therapy intensives, I do see partners 1:1 for one portion of the intensive.

For couples, yes! It is imperative that couples join their online session with me from the same physical location. I do not meet with couples online who are joining from different locations. For family therapy, especially adult family therapy, parties do not need to join from the same physical location, although it is best if they can.

For family therapy, all parties do not need to be present for every session. Depending on how many family members there are and what their goals are with each other, sometimes we may meet in smaller groups of two or three instead of the entire family of five, for example.

I work with heterosexual couples, LGBTQ+ couples and nonbinary or gender nonconforming people and relationships. I also work with polyamorous relationships—typically those that are already established. I welcome any person looking for help with their relationship into my office. Although sex therapy is not my specialty, I do help couples with their sex life and am sex positive and kink friendly. However, if sex therapy is primarily what you are looking for, I will happily recommend you to a colleague who specializes in this work.

Yes, please email me at sandra@ctr4excelmft.com to get on a waitlist for weekly therapy. If you would like to work with me, but my calendar is currently full, I do offer couples therapy intensives, which are a great option for couples wanting help now. They can lead to breakthroughs, a decrease in tension, and an increase in connection. These are as short as 4 hours and as long as 2 days.

If these options don’t appeal to you, here are a few local relationship therapists I refer to:

Tacoma:
Allie Peyton
Jenn Parretta
Maria Carrington

Seattle:
Seattle Clarity Counseling
Lia Schaefer
Ben Trelease

If you are specifically looking to do individual therapy with an ISTDP therapist licensed in WA, FL or UT, I am happy to put you on a waitlist.

I do not offer consultations to prospective clients. I find that talking about what might happen in therapy or about how I work is not an accurate measure for whether or not therapy will work for you--it is simply a sales pitch, which is only an accurate representation of my ability to sell my services, rather than a measure of my therapy skills. The only way to know if therapy works for you is to try it out and see. Our first appointment together is longer for a few reasons, a) to help me assess what you're struggling with and whether I can help; b) to help you experience therapy with me and know by the end if it has helped or not. How you feel will speak for itself. If it has not been helpful for you or I determine I won't be able to help you, I can give you the best referrals because we've spent some time together and I have a good idea of what would be most helpful. It's a win-win.