Disclosure Statement

I hold a masters degree in counseling from San Jose State University and am a Licensed Professional Counselor* (license # 6248) in the state of Colorado. I additionally have a bachelors degree in Anthropology from the University of Vermont. I am a member of the American Counselors Association (ACA).
Note: You may fill out the electronic form below or print the disclosure statement and bring it in to your first appointment.

As a client receiving therapeutic services, you have the right to the following information

Therapeutic Methods

You are entitled to receive information about the methods and techniques used in therapy sessions, the duration of therapy (if known), and the fee for therapy services provided. Please ask if you have questions in those areas.

Second opinion and termination

You may seek a second opinion at any time. You may terminate the therapeutic relationship at any time.

Sexual Intimacy

Sexual intimacy is never appropriate in a professional relationship, such as with therapist and client, and should be reported to the board that licenses, certifies, or registers the therapist.

Confidentiality

Generally speaking, information provided by and to a client in a professional relationship with a therapist is legally confidential, and the therapist cannot disclose the information without the client’s consent. There are several legal exceptions to confidentiality which include:
(a) I am required to report any suspected incident of child (18 and under) or elder abuse or neglect to law enforcement
(b) I am required to report any threat of imminent physical harm by a client to law enforcement and to the person(s) threatened
(c) I am required to initiate a mental health evaluation of a client who is imminently dangerous to him or herself or other(s), or who is gravely disabled, as a result of a mental disorder
(d) I am required to report any suspected threat to national security to federal officials
(e) I may be required by Court Order to disclose treatment information.
(f) Your case may be discussed, without identifying information, in consultation with my colleagues.

I will inform you of any other legal exceptions to confidentiality if they arise in therapy, or you may read about them in Colorado Revised Statute § 12-43-218.

*The practice of psychotherapy by any person, both licensed or registered, is regulated by the Mental Health Licensing Section of the Division of Registrations. The Board of Licensed Professional Counselors Examiners regulatory boards can be reached at (1560 Broadway, Suite 110, Denver CO, 80202 and (303) 894-7855). The regulatory requirements for mental health professionals provide that a Licensed Clinical Social Worker, A Licensed Marriage and Family Therapist, and Licensed Professional Counselor must hold a master’s degree in their profession and have two years of post-master’s supervision. A Licensed Psychologist must hold a doctoral degree in psychology and have one year of post-doctoral supervision. A Licensed Social Worker must hold a master’s degree in social work. A Psychologist Candidate, a Marriage and Family Therapist Candidate and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure.  A Certified Addiction Counselor I (CAC I) must be a high school graduate and complete required training hours and 1,000 hours of supervised experience.  A CAC II must complete additional required training hours and 2,000 hours of supervised experience. A CAC III must complete additional required training hours and 2,000 hours of supervised experience. A Licensed Addition Counselor must have a clinical master’s degree and meet the CAC III requirements. A Registered Psychotherapist is registered with the State Board of Registered Psychotherapists, but is not licensed or certified, and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the State.

Clients

When I consult with parents regarding children and adolescent clients under age 18, specific content of the therapy sessions will be held in confidence unless client welfare requires that parents have access to such information. In most cases, I will arrange joint meetings between minor clients and their parents as a part of the therapy process.

Couple Clients

In couples counseling, information disclosed by one partner when the other partner is not present will not be kept confidential from the other partner. Information disclosed in couples therapy will not be released to other parties without signed consent from both partners.
 

Billing Information

If you choose to pay by credit card, or if I charge your credit card for a missed appointment or a phone consultation lasting longer than 10 minutes, the amount, date of charge, and my business name will appear on your credit report, producing a record of services visible to your credit card company. No specific content of our sessions (e.g. diagnosis, treatment plan, session notes) will be disclosed to billing or credit agencies without your signed consent.


Session Length

After your initial 20-minute complementary phone consultation, typical counseling sessions will be 50 minutes in length. If you are late, you are welcome to receive whatever time remains of your appointment as initially scheduled. If an emergency prevents me from beginning our session on time, I will prolong our initially scheduled time or reschedule with you to ensure that you receive the full scheduled time.


Fees

A 50-minute session is $120. There is no charge for session cancellations or schedule changes as long as they are made 24 hours in advance of the originally scheduled time. Sessions that are missed or canceled less than 24 hours in advance will be charged to your credit card at the regular rate of $120. Phone calls lasting longer than 10 minutes will be charged to your credit card at the normal prorated rate.
 

Payment Procedures

I accept cash, personal checks, or credit card payments. If a personal check is returned, a $31 service fee will be added to the original amount of the check and charged to your credit card. These direct billing methods safeguard our relationship by allowing our interactions to focus on progress toward your goals, rather than on payment logistics and delays. They also allow me to avoid disclosing your billing information to administrative assistants, collection agencies, or independent billing companies aside from your personal credit card company. I will safeguard your credit card information by storing all consent forms and identifying information in a locked cabinet and using up-to-date encryption programs in all online credit card billing procedures.
 

Phone Policies

To contact me, please leave a message on my confidential voice mail at 303-241-3571 and I will return calls within 24 hours. If you do not hear from me within that time, please call me again, inform me of the delay, and I will return your call as quickly as possible. If an emergency arises that requires immediate response and I am away from my phone, please call 911 or contact the community health center for your county: Boulder County 303-447-1665 (24-hour crisis line), Longmont Area 303-678-6200 (8 AM to 5 PM), Denver County 303-436- 6266 (24-hour crisis line).
 

Vacations

When I go on vacation, I will provide you with advanced notice so that you can plan for the continuity of your therapy process. If you would like the contact information for an alternate therapist to schedule an appointment in my absence, ask me to help you make arrangements ahead of time with another therapist. If a crisis arises during this time, you may call the alternate therapist, the crisis lines listed above, or 911.
 

Client Expectations

There are several things that you can do to increase the effectiveness and efficiency of your therapy process. By attending every session, arriving on time, using the restroom before your appointment, and turning off all electronic equipment, you can remove delays and distractions that get in the way of in-session progress. You may make the most of your time between sessions by completing homework assignments that we agree upon in session; keeping a record of thoughts, dreams, and feelings pertaining to your therapy goals; clearing time in your schedule to process what you are learning; and enlisting the help of other people in your life who can support you in your growth efforts. You may ask me to recommend books, movies, articles, workshops, or other resources that will help your progress in therapy.

Terms & conditions *
Date *
Date
By entering your name here, you are e-signing this document, accepting the terms *
By entering your name here, you are e-signing this document, accepting the terms
Date of birth *
Date of birth
Address *
Address
Preferred Phone (home, cell or work) *
Preferred Phone (home, cell or work)
Alternate phone
Alternate phone
Enter name and relationship to client.
Emergency Contact Phone *
Emergency Contact Phone

**Although forms submitted digitally come directly to me, due to the nature of email, the complete confidentiality of forms submitted electronically can't be guaranteed.