Consent, Disclosure, & Policies Form
Welcome to Colorado Counseling Center, PLLC. We are required by the State of Colorado and the Department of Regulatory Agencies to share the following information with you to help establish the understanding and trust essential to a therapeutic relationship. Please provide the requested information and read these documents carefully, as they contain important information about our practice, policies, and how your mental health information can be used and disclosed. Please note any questions or concerns that you have—you may discuss these with your therapist at any time. After you sign the enclosed documents, they will constitute a binding agreement between you, your assigned primary therapist, and Colorado Counseling Center, PLLC (hereafter referred to as “Colorado Counseling Center,” “CCC,” or “the Center”).
Colorado Counseling Center consists of a group of mental health therapists, including employees and independent contractors. While you, the client, always have the choice in determining which therapist you want to see, CCC will do their best to set you up with a therapist best suited for you. If the requested therapist is not available, CCC will recommend another therapist at CCC or refer you to a therapist outside of CCC. Your primary therapist, (hereinafter “therapist” or “primary therapist”) will be solely responsible for this disclosure statement and all therapeutic treatment they provide to you. If you have any questions or concerns about your treatment, please speak with your primary therapist.
Your primary therapist is: Marion GoodwinKevin HalesBrooke HumpreysLisa RosenPaul Sigafus
SPECIAL INSTRUCTIONS REGARDING CHILDREN & TEENS IN THERAPY: Any child under the age of fifteen (15) years of age must have a parent or legal guardian consent to the mental health services to be provided. Parents of teens 15-18 may also consent to mental health services on behalf of their child (this is the recommended course of action if parents are paying for the services and/or if they want to communicate with the therapist about the services provided). Any child fifteen (15) years of age or older may sign the below form and consent to mental health services without the consent of a parent or legal guardian. If the parent or legal guardian is consenting to the mental health services, the required disclosures shall be made to the parent or legal guardian. If the child is consenting to mental health services, the required disclosures shall be made to the child. If a parent or legal guardian is consenting to mental health services for his/her minor child, and the parent or legal guardian is divorced or separated, the parent is required to provide a copy of the Court Order and/or Custody Agreement that grants the parent or legal guardian authority to consent to mental health services. Failure to provide a copy of the Court Order or Custody Agreement will result in immediate termination of therapy. It is solely your responsibility to provide this information to your therapist.
As a collaborative process, therapy requires your very active effort, honesty, and openness in order to achieve desired changes. You may also be contacted periodically by Colorado Counseling Center to get feedback on the quality of services you are receiving. You may always request that Colorado Counseling Center not contact you to receive feedback on the quality of services you receive.
The process of engaging in therapy can result in your experiencing considerable emotional discomfort. Your therapist may challenge your perceptions or propose ways of handling situations that can cause you to feel some distress. Attempting to resolve therapeutic issues may result in changes that were not originally intended. Therapy may also result in decisions that may be positive for one family member, but could be viewed negatively by another. Change will sometimes be easy and swift; other times it will be slow and even frustrating. There is no guarantee that therapy will yield the intended results. At all times, it is your decision whether to pursue the suggestions made by your therapist. It is always your responsibility, not your therapist’s, to make decisions regarding relationships such as cohabitation, marriage, divorce, separation, reconciliation, custody, etc.
You are entitled by law to receive information about the methods of therapy, the techniques used, the duration of therapy, if known, and the fee structure. During the course of therapy, your therapist at Colorado Counseling Center is likely to draw on various therapeutic approaches according, in part, to the problem that is being treated and the therapist’s assessment of what will best benefit you. Within a reasonable period of time after the initiation of treatment, your therapist will be able to offer you some impressions of what your therapy will include. You should also make your own assessment about whether you feel comfortable working with your therapist. If you have any questions about the process of therapy, please let your therapist know directly.
The most common reason for ending therapy is that a client’s concerns have been addressed. You are entitled to end therapy or seek a second opinion from another therapist at any time. Most clients find it helpful to have one or two sessions to bring closure to therapy and discuss the therapeutic process. These sessions can help prevent future problems. Therapy can also end when your challenges lie beyond the limits of your therapist’s ability to help. If this becomes apparent to your therapist at any point, your therapist is legally required to refer, terminate, or consult, and will discuss this with you, offer you appropriate referrals, and end treatment.
By signing this document, you affirm your understanding that should you discontinue therapy for more than 60 days without written notice to CCC, your treatment will be considered “terminated.” You may resume therapy anytime after the 60-day period by communicating your decision to resume therapy services to CCC. This document may remain in effect should you resume therapy if one (1) year has not elapsed since your last session. However, you may be asked to re-sign this document or provide additional information to update your client records and/or sign new forms. “Discontinuing therapy” means that you have not had a session with your therapist for at least sixty (60) days.
* Names listed in alphabetical order.
Marion Goodwin: Degrees: Fordham University, MSW in Social Work, 1996; Nazareth College, B.A. in Sociology/Social Work, 1990. License: Licensed Clinical Social Worker, Colorado LCSW # 09924872
Kevin Hales: Degrees: Liberty University, M.A. in Professional Counseling, 2014; Brigham Young University, B.S. in Marriage, Family, & Human Development, 2001. License: Licensed Professional Counselor, Colorado, LPC.0013095
Brooke Humphreys: Degrees: University of Colorado Denver, M.A. in Couples and Family Therapy, 2018; Colorado State University, B.A. in Human Development & Family Studies; License: Licensed Professional Counselor Candidate, Colorado, LPCC.0016648 As a provisionally licensed clinician (LPCC), Brooke is currently under supervision for full licensure as a Licensed Professional Counselor. Brooke’s clinical supervisor is Paul Sigafus, LMFT; he can be reached at Colorado Counseling Center by calling 720-468-0101, ext. 1.
Lisa Rosen: Degrees: Antioch University, M.S. in Clinical Psychology, 2005; University of Colorado, B.A. in Psychology, 1998. License: Licensed Professional Counselor, Colorado LPC.0013527(Name on license: Elizabeth Rosen)
Paul Sigafus: Degrees: University of Maryland, College Park, M.S. in Marriage & Family Therapy, 2003; Brigham Young University, B.S. in Marriage, Family, & Human Development, 2001. License: Licensed Marriage & Family Therapist, Colorado LMFT 815
Regulation of Psychotherapists in Colorado: The Colorado Department of Regulatory Agencies (DORA), Division of Professions and Occupations (“DOPO”) has the general responsibility of regulating the practice of licensed psychologists, licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists, certified school psychologists, and unlicensed individuals who practice psychotherapy. The agency within DORA that has responsibility specifically is the Mental Health Section, 1560 Broadway, Suite #1350, Denver, CO 80202, (303) 894-2291; DORA_MentalHealthBoard@state.co.us. Specifically the State Board of Marriage and Family Therapist Examiners regulate Licensed Marriage and Family Therapists; the State Board of Social Work Examiners regulates Social Workers; and the State Board of Licensed Professional Counselor Examiners regulates Licensed Professional Counselors and all State Boards may be reached at the address listed above. Clients are encouraged, although not required, to resolve any grievances through our internal process.
Levels of Regulation Include: Licensing (requires minimum education, experience, and examination qualifications), Certification (requires minimum training, experience, and for certain levels, examination qualifications), and Registered Psychotherapist (does not require minimum education, experience, or examination qualifications). All levels of regulation require passing a jurisprudence take-home examination. The following are the requirements for each type of Mental Health Professional: Certified Addiction Counselor I (CAC I) must be a high school graduate, complete required training hours and 1,000 hours of supervised experience. Certified Addiction Counselor II (CAC II) must complete additional required training hours and 2,000 hours of supervised experience. Certified Addiction Counselor III (CAC III) must have a bachelor’s degree in behavioral health, complete additional required training hours and 2,000 hours of supervised experience. Licensed Addiction Counselor must have a clinical master’s degree and meet the CAC III requirements. Licensed Social Worker must hold a masters degree in social work. 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. Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a masters degree in their profession and have two years of post-masters supervision. A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision. Registered Psychotherapist is a psychotherapist listed in the State’s database and is authorized by law to practice psychotherapy in Colorado but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state.
PAYMENT AND FEES:
Annual Fee Changes: Colorado Counseling Center adjusts its fees on an annual basis, beginning January 1stof each year.Additional Credentialing: If your counselor earns additional certifications/licenses, their fee may also change from time to time to reflect that additional credentialing.
Future Notices Regarding Fee Changes: If you are still attending therapy in our practice at the turn of a year or when your counselor earns other credentials, you will be notified of any applicable changes by your therapist in session or by email. Updates to our fees will also be listed on our website at coloradocounselingcenter.com/fees.
Cancellation and No-Shows: Since your appointments involve the reservation of time specifically for you, and out of respect for your therapist, a minimum of 24 hours advance notice is required for rescheduling or canceling an appointment, excluding emergency situations. Anytime you fail to attend a scheduled appointment without giving any notice of cancellation, you will be charged the full fee amount of your session. The first session that is missed by canceling within the 24-hour window will be charged a $50 fee. After that, a full fee will be charged for each cancellation within the 24-hour window. If you cancel and do not then reschedule and attend an initial appointment, the full fee of your scheduled session will be charged for the late cancellation. Repeated cancellations (more than two) without the required 24 hours’ notice may result in the termination of therapy. Multiple no-shows will result in the termination of therapy. Although CCC may send clients email reminders about upcoming appointments, this is done as a courtesy and only if you consent to receive such communications by providing your email. It remains your sole responsibility to keep track of and attend all scheduled therapy appointments, whether or not you receive the email reminder.
Overdue Payment: If your account is more than 90 days overdue, and suitable payment arrangements have not been made, CCC will turn your account over to Debt Recovery Resources, a collections agency out of Ft. Worth, Texas, and provide Debt Recovery Resources all information deemed necessary by them in order to collect monies owed to CCC. (If legal action is necessary, the costs incurred will be added to your account.)
Third Party Payments (by Clergy or other family members): When clergy or other family members offer to pay, in full or in part, for the services you receive at CCC, you may be asked to make a copayment at the time of each session. If the third party is unable to pay for any reason, you remain personally responsible for the full fee. Any cancellation/no-show fees will be charged directly to you. If you do not have a co-payment, CCC will still collect your credit/debit card information before or at the first session to enable timely payment for any cancellation/no-show fees. If a third party is making a payment on your behalf, Colorado Counseling Center will not disclose confidential information to the third party without your written consent.
Insurance: We do not bill or interact with insurance companies directly. At your request, your therapist will provide you with a statement that you can then submit to your insurance company for reimbursement. Please be aware that submitting an invoice for reimbursement carries a certain amount of risk, as we cannot control how your information is used once submitted. Not all therapeutic issues are reimbursable; it is your responsibility to verify the specifics of your coverage. Insurance companies normally do not reimburse for missed appointments or late cancellation fees.
Phone Contact: It is CCC’s policy to try to return all telephone messages by the following business day, although that may not always be possible. Our therapists check their messages a few times a day, though rarely during non-business hours. They may not be available to converse or check messages on weekends, holidays, and when they are out of town. Messages left during these times will be returned in a prompt manner when the therapist returns to work. CCC only provides non-emergency services by scheduled appointment. *Please note that therapeutic calls lasting 10 minutes or longer are billed pro-rated at the regular fee.
Teletherapy: In general, Colorado Counseling Center does not provide Teletherapy, such as therapy over video chat. Should you want teletherapy, you must discuss your request with your therapist, however, it is in your therapist’s sole discretion whether to accommodate your request.
Texting/Messaging Policy: Please do not use text messages or messaging on Social Networking to contact your therapist and/or CCC. Social media sites are not secure and your therapist may not read these messages in a timely fashion. Because it is not possible to guarantee the confidentiality of text messages (e.g., we cannot be sure that it is you sending the text), it is CCC’s policy that we do not text with clients. If you have information that you need to communicate to your therapist, please call your therapist directly.
Email Policy: Please use discretion in deciding whether to communicate with your therapist via email. CCC cannot be held responsible for any information lost in transit or viewed by a third party. Email should only be used for brief, general questions (e.g., questions regarding billing or advance scheduling of appointments). Hence, therapeutic issues, emergencies, sensitive personal information, and cancellations should all be communicated to your therapist only over the telephone or in person. Although confidentiality cannot be guaranteed when using email communications, confidentiality will extend to information obtained through email communication.
Social Media Policy: Please do not request your therapist and/or CCC to “follow” or “friend” you etc. via any social media. Any such request will be denied in order to maintain professional boundaries. Do not use wall postings, @replies, or other means of engaging with your therapist and/or CCC in public online if you have an already established client/therapist relationship with a therapist at CCC. Engaging in this way could compromise your confidentiality. It may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart. Although CCC may have a business Facebook Page, Blog, or other business social media accounts, there is no requirement that you “like” or “follow” CCC on social media. If you choose to “like”, “follow”, or post comments on CCC’s social media accounts/blog, there is the chance that others will see your name associated with CCC. Any comments you post regarding therapeutic work between you and your therapist will be deleted as soon as possible after CCC becomes aware of such posts. By signing this form, you agree that you will refrain from discussing, commenting, and/or asking therapeutic questions via any social media platform. You agree that will not use social media to communicate any therapeutic comments and/or questions to CCC therapists.
Emergencies: Colorado Counseling Center does not provide emergency care or crisis services. Our therapists are often not immediately available by telephone. They do, however, check periodically for telephone messages. If you need to talk to someone immediately and are having an emergency, call 911 or the 24-hour Rocky Mountain Crisis Center at 1-844–493–TALK (8255), text or go to your nearest hospital emergency room. You are solely responsible for all costs arising from such care.
Litigation Limitations: If you are involved in divorce/custody litigation, your therapist’s role is not to make recommendations to the court concerning custody or parenting issues. The court can appoint professionals to conduct an investigation/evaluation and make recommendations to the court in the best interest of your children. Any request to testify / participate in any litigation will be charged directly to the client/s at $300/hour, as stated previously.
Electronic Records: Colorado Counseling Center may keep and store records for each client electronically on CCC’s computers and some mobile devices. In order to maintain security, Colorado Counseling Center employs the use of passwords and encryption methods to protect computers from unauthorized access. In addition, Colorado Counseling Center may also use electronic backup or storing systems either by using external hard drives, thumb drives or similar methods, or on a cloud-based service. The cloud-based records system CCC uses is therapynotes.com. This is to help prevent the loss or damage of records. CCC maintains the security of these backup devices through HIPAA compliant encryption and passwords. The cloud-based backup and storing systems means that the backups are stored on computers that are connected to the internet. In order to maintain security of these backups CCC has employed the following procedures: (1) Entered into a HIPAA Business Associates Agreement with the cloud-based company. Because of this Agreement, the company is obligated by federal law to protect these backups from unauthorized use or disclosure; (2) The computers on which these backups are stored are kept in secure data centers, where various security measures are used to maintain the protection of the computers from physical access by unauthorized persons; (3) The company employs various security measures to maintain the protection of these backups from unauthorized use or disclosure; (4) Other individuals may have access to these backups such as Company’s workforce members in order to maintain the system itself, and federal law protecting the backups extends to these workforce members.
Maintenance of Client RecordAs a client, you may request a copy of your Client Record at any time. In accordance with the Rules and Regulations outlined by DORA, CCC will maintain your client record (consisting of disclosure statement, contact information, reasons for therapy, notes, etc.) for a period of seven (7) years after the termination of therapy or the date of our last contact, whichever is later. CCC cannot guarantee a copy of your Client Record will exist after this seven-year period.
Generally speaking, the information provided by and to a client during therapy sessions is legally confidential if the therapist is a certified school psychologist, a licensed social worker, a licensed marriage and family therapist, a licensed professional counselor, a licensed psychologist, or a registered psychotherapist. If the information is legally confidential, the therapist cannot be forced to disclose the information without the client’s consent. Information disclosed to a licensed marriage and family therapist, a licensed social worker, a licensed professional counselor, a licensed psychologist, a registered psychotherapist, or a certified/licensed addition counselor is privileged communication and cannot be disclosed in any court of competent jurisdiction in the State of Colorado without the consent of the person to whom the testimony sought relates.
Exceptions to this general rule of confidentiality are in C.R.S. §12-43-218. Such situations in which the law requires disclosure include, but are not limited to the following:
You should also be aware of the following additional Confidentiality Policies of Colorado Counseling Center:
My signature below affirms my informed and voluntary consent to enter therapy (and/or have my child/children enter therapy), and that I have read and understand the preceding information, including the office policies and procedures and the nature of confidentiality in therapy. I affirm that the information provided on the New Client Information Form is true and accurate, including (if applicable) all information about third parties who may be helping with payments. I have had an opportunity to ask questions and have had my questions answered satisfactorily. I affirm that prior to becoming a client of Colorado Counseling Center, I was given sufficient information to understand the nature of therapy, including the possible risks and benefits. I understand that I have full access to this form online at coloradocounselingcenter.com/forms. I acknowledge that if I wish to have a copy of the signed document, I may request one in writing at any time. I understand that I can ask questions and raise concerns about the treatment at any time and that I may terminate therapy at any time by providing written notice to Colorado Counseling Center. Therapy shall be terminated upon receipt of my written notice.
If you are consenting to therapy for a minor, please indicate your relationship to the client:
Leave this empty:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Consent, Disclosure, & Policies Form
Agree & Sign