Counseling Disclosure and Consent Form
Suandria Hall, MA, LPCC, NCC, CO Registered Psychotherapist
p: 720.772.6967 I e:
SUPERVISION INFORMATION You understand that I am a Licensed Professional Counselor Candidate (LPCC). I am required to be under the ongoing supervision of an approved licensed clinical therapist with whom the content of your sessions may be shared. Therapy may also include consultations with other appropriate licensed professionals. By signing this disclosure and consent, you allow me to discuss your case in supervision. My supervisor is:
Chaya M. Abrams, LPC, LAC, PhD Candidate
Professional Counselor, Counselor Educator and Supervisor
2687 North Park Dr. Suite 104, Lafayette, CO 80026
e: firstname.lastname@example.org, p: 303-947-3356
SESSION LENGTH, FEE INFORMATION, AND DURATION OF COUNSELING
● Unless otherwise agreed upon, counseling fee is $100 per session and fifty (50) minutes in length, beginning at the appointment time, not when the client arrives.
● Walk and Talk. Sessions are held at a predetermined location. Confidentiality cannot be guaranteed. If by chance we run into someone you know, then I will follow your lead and will never compromise your confidentiality. It is up to you to acknowledge me as your therapist if you choose to do so; the choice is completely up to you. If someone I know says hello, I will maintain your confidentiality and will not acknowledge you as my client without your signed permission.
● Telehealth/Virtual session. I use doxy.me. This private virtual office is HIPPA secure, no download required, and free to use.
● Fees and Payments.
Payment due at the end of session.
Forms of payment accepted: Ivy Pay or cash. Ivy Pay is HIPPA secure. You will receive a text notification to make payment.
Cancellations or reschedules must be made at minimum 24 hours prior to your original scheduled appointment date and me. Cancellations or reschedules made less than 24 hours of your original appointment date and time will incur a cancellation fee of $100.
● Counselor and supervisor reserve the right to recommend termination of counseling or referral of a client for a more appropriate level of care
CLIENT PARTICIPATION Please arrive promptly for your scheduled appointment. Contact me at least 24 hours in advance if you are unable to attend a scheduled appointment. Two consecutive missed appointments may result in your counseling being discontinued. Sessions begin at the appointment time, not when the client arrives. Sessions end at the scheduled time regardless of when the session started. Please notify me if you are going to be late. I will only wait 15 minutes past the scheduled appointment time.
REGULATION OF PSYCHOTHERAPISTS
The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Sec on of the Division of Registrations. The Board of Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800. As to the regulatory requirements applicable to mental health professionals:
* 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.
* 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 master’s 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 master’s 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.
CLIENT RIGHTS AND IMPORTANT INFORMATION
1. You are entitled to receive information from your therapist about the methods of therapy, the techniques used, the dura on of your therapy (if known), and the fee structure. You can seek a second opinion from another therapist or terminate therapy at any me.
2. In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant or certificate holder.
3. As a client please understand I provide non-emergency counseling services by scheduled appointment. If for any reason you are unable to contact your counselor by phone, and are having a true emergency, you agree to call 911 or check yourself into the nearest hospital emergency room.
4. Generally speaking, the information provided by and to a client in a professional relationship with a psychotherapist is legally confidential, and the therapist cannot disclose the information without the client’s consent. There are several exceptions to confidentiality which include: (1) I am required to report any suspected incident of child abuse or neglect to law enforcement; (2) I am required to report any threat of imminent physical harm by a client to law enforcement and to the person(s) threatened; (3) If I receive information concerning a serious threat of physical harm to yourself or others, I have to take specific actions which may include; notifying law enforcement authorities, informing another person of possible physical harm, calling 911 or another appropriate person to initiate a mental health evaluation. (4) I am required to report any suspected threat to national security to federal officials; and (5) I may be required by court order to disclose treatment information.
5. I understand that this form is compliant with HIPPA regulations and no medical or no psychotherapy information, or other information related to my privacy, will be released without permission unless mandated by Colorado law. Consistent with HIPPA guidelines authorization for release and consent for treatment will be automatically revoked one year after the signing date.
6. If you are involved in divorce or custody litigation, my role as a therapist is not to make recommendations to the court concerning custody or parenting issues. By signing this Disclosure Statement, you agree not to subpoena me to court for testimony or for disclosure of treatment information in such litigation; and you agree not to request that I write any reports to the court or to your attorney, making recommendations concerning custody. The court can appoint professionals, who have no prior relationship with family members, to conduct an investigation or evaluation and to make recommendations to the court concerning parental responsibilities or parenting me in the best interests of the family’s children.
MINORS In cases when treating a minor, (a child under age 18) I agree to obtain proper consent. We will need both parent’s parental consent, or the consent of the court-appointed guardian or whomever has custody. There are cases when a child is age 15 or older and has sought counseling on his/her own. In this case, the child will need to sign his/her own disclosure and consent form for counseling.
COUPLES AND FAMILIES Within the context of couple or family therapy, there is a “no secrets” policy, meaning that all members of the couple or family in treatment together are treated equally and your therapist will not keep secrets from other members within that specific therapeutic setting.
MEETING IN PUBLIC In the event that we meet inadvertently in public, in order to protect your privacy, I will not approach you or speak to you. If you wish to acknowledge the acquaintance and speak to me, it is your choice to do so. It is my policy not to engage in social activities with, nor accept gifts from clients.
I have read the above information, it has also been provided verbally, and I understand the rights and limitations as a counselee receiving counseling.