Individual Disclosure

Date *
Date
Client'sName *
Client'sName
Address *
Address
Phone *
Phone
Marital Status *
Section
FOR CLIENTS 18 AND UNDER
Mother's Phone
Mother's Phone
Father's Phone
Father's Phone
Child Lives With
If the child’s parents are divorced, please indicate which parent has parental responsibility/authority for medical and/or mental health decision-making

DISCLOSURE STATEMENT AND EXPLANATION OF FEE POLICY

 

Credentials
I am a licensed clinical psychologist in the state of Colorado.  I earned a doctorate in clinical psychology from the University of Denver’s Graduate School of Professional Psychology (an American Psychological Association approved program) in 2001

I received a Masters degree in Counseling Psychology at the University of Denver’s Counseling Psychology program in 1984.  Following, I completed a two-year postgraduate training in marriage and family therapy.  I was licensed as a marriage and family therapist in Colorado from 1993 to 2005.

Lastly, I completed a two-year postgraduate program in psychoanalytically oriented psychotherapy at the Denver Institute for Psychoanalysis in May 2006.

I have worked in the mental health field since 1985 and have held a private practice since 1989.  In addition, I have worked in various mental health clinics and hospitals in the Denver area, served as a consultant to other professionals, taught courses and conducted workshops on various topics.  Please ask if you wish to receive more details about my professional background.

Client Rights Disclosure
The practice of both licensed and unlicensed persons in the field of psychotherapy is regulated by the Colorado Department of Regulatory Agencies.  Any questions, concerns, or complaints may be directed to:

Mental Health Occupations Grievance Board
1560 Broadway, Suite 1340
Denver, Colorado 80202
Phone: 303-894-776

You are entitled to receive information about my method of therapy, the techniques used, the duration of the therapy (if I can determine that), and my fee structure.  If you have any questions about my services or fees, please feel free to discuss them with me so we can reach a fair understanding.  You may seek a second opinion from another therapist or may terminate your therapy with me at any time.  

In a professional relationship (such as ours) sexual intimacy is never appropriate and should be reported to the grievance board listed above.  The information provided by you to me in psychotherapy sessions is legally confidential, except in life-threatening situations, and/or suspicion of child or elder abuse. 

I am an independent practitioner.  I am not professionally or legally affiliated with any other professional.  Although I share an office suite with other psychotherapists each of the practices are independent and the policies are different.

Psychological Services
The practice of psychotherapy is not easily described in general statements.  It varies depending on the training and personality of the therapist, the personality of the client, and the presented problems.  In the course of a treatment, a number of different approaches may be utilized depending on the issues that need to be addressed.  Your commitment to work both during and away from our sessions can determine the greatest potential for success.

Psychotherapy has both benefits and risks.  Since the process of therapy includes discussing unpleasant aspects of your present life and/or your history, you may at times experience uncomfortable feelings such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness.  Psychotherapy has also shown to have many benefits for people who undertake it.  It often leads to significant reduction of distress, resolution of specific problems, and better relationships.  However, there are no guarantees about what you may experience during therapy or the outcome.

Treatment always begins with an assessment of your needs.  I can typically provide you with my initial impression of what our work may entail and discuss a treatment plan with you within the first 2-3 sessions.  You should evaluate this information along with your own assessment of whether you feel comfortable working with me.  Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select.  I am happy to discuss any questions that you may have about my procedures at any point during our work together.  I welcome you to bring up and discuss any doubts that you may feel about working with me.  If your doubts persist, I would be happy to help you secure a consultation with another psychotherapist.

Fee Policy and Procedures
My practice is a fee for service practice.  The fee for psychotherapy is $160 per 45-minute session (individual psychotherapy), and $185 per 55-minute session (couples & family therapy).  I charge $200 per hour for other professional services you may require, such as evaluation, consultation, report writing, telephone conversations, email or text exchanges which last longer than ten minutes, attendance at meetings, or consultation with other professionals which you have authorized, preparation of records or treatment summaries, or the time required to perform any other services which you may require of me. Extended sessions (individual, couples or family) are also charged based on $200 per hour rate

Payment is due at the time of the visit, unless other arrangements have been made previously.  I accept cash, check, Visa and MasterCard. Appointments not kept or cancelled without one full business day’s notice will be charged at your regular fee rate. 

I will provide you with a monthly statement at the end of each month with billing and payment information, diagnosis and insurance codes.  It is your responsibility to submit this form to your insurance company for reimbursement and pursue the claim.  

I request that all clients provide their credit card information.  This information will be kept in a secure place.  If you wish to pay by credit card a charge will be applied to your card after each completed service.  A charge will also be applied to your credit card for each appointment that is not cancelled without a full business day’s notice.  For clients who choose to pay by cash or check, their credit card will be charged only if regular and/or late charges have not been otherwise resolved.

Late Payment Policy
Payments overdue by 30 days will incur an automatic $25 late charge.  There will be an additional $25 late fee added to your bill for each additional month that your balance remains unpaid.

I will charge your credit card for any missed appointments that have not been cancelled without the required one full business day notice, and have not been paid otherwise.  All charges outstanding beyond 60 days including late fees will also be billed to your credit card. 

In the case of unpaid balances outstanding for greater than 60 days which cannot be otherwise resolved, I reserve the right to seek a settlement of the balance due through either a collection agency or small claims court.  No evaluation reports or other records will be released until the balance is paid in full.

Insurance Reimbursement
If you have a health benefit policy, it will usually provide some coverage for mental health services.  You may send a copy of your monthly statement to your insurance company for reimbursement.  I will also provide you with any additional assistance you may need, such as filling out forms, to facilitate your receipt of your benefits.  However, you, and not your insurance company, are responsible for the payment of your fees.  It is important that you find out exactly what mental health services your insurance policy covers.  Please call your insurance provider to find out about the specifics of your coverage

Most insurance companies require you to authorize me to provide them with a clinical diagnosis, and sometimes additional clinical information such as treatment plans or summaries.  In rare cases they may request a copy of your entire record. This information will become part of the insurance company files and will probably be stored in a computer.  Though all insurance companies claim to keep such information confidential, I have no control over what they do with your records once it is in their hands.  In some cases, they may share the information with a national medical information databank.  If you request, I will provide you with a copy of any report I submit to your insurance provider.

It is important to remember that you always have the option to pay for my services yourself and avoid the potential complexities of dealing with insurance.

PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep treatment records.  You are entitled to receive a copy of your records, or I can prepare a summary for you instead.  Because these are professional records, they may be misinterpreted and/or upsetting.  If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents.  Clients will be charged an appropriate fee for any professional time required to comply with an information request.

Under the Colorado Mental Health Practice Statute I am required to notify you in writing that as a licensee, registrant, or certificate holder I may not maintain your records after the seven-year period required for filing a complaint pursuant to section 12-43-224(1)(a)(1).

CONFIDENTIALITY
In general, the law protects the privacy of all communications between a client and a psychologist.  I can only release information about our work to others with your written permission. 

However, there are a few exceptions to the general rule of confidentiality.  In most legal proceedings, you have the right to prevent me from providing any information about your treatment.  In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it.

There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I must file a report with the appropriate state agency.

If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions.  These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client.  If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. 

These situations have rarely arisen in my practice.  If such a situation does arise in your treatment, I will make every effort to fully discuss it with you before taking any action.

While this summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns you may have.  The laws governing these issues are complex, and I am not an attorney.  I am happy to discuss these issues with you, however, should you need specific advice, I would recommend that you seek formal legal consultation.

Contact with Other Care-providers
I feel it is important to coordinate your care with other medical or mental health practitioners you are seeing and usually will request that you sign a release of information to allow me to do so.

Additionally, I may occasionally find it helpful to consult other professionals about a case. During a consultation, I always maintain the confidentiality of the client’s identity.

Please note that cellular phone and e-mail communications are vulnerable to breeches of confidentiality due to their modes of information transmission.

CONTACTING ME
I am often not immediately available by telephone. While I generally work between 8am and 5pm, I do not answer the phone when I am with a client. My telephone is answered by a confidential voice mail system that I monitor frequently. I will make every effort to return your call on the same day, with the exception of weekends and holidays. If you are difficult to reach, please inform me of a few times when I would be able to reach you directly. 

When I am out of the office and unavailable for an extended period of time, I will provide you with the name of a trusted colleague to contact, if necessary.

I correspond with my clients via e-mail or text for the purpose of scheduling or rescheduling appointments only. If you wish to discuss any issues related to your treatment that cannot wait till our next session or need to reach me quickly please contact me by phone. I check my e-mail no more than once a day, and never during the day when I am typically meeting with clients.  The best and fastest way to reach me is to call my office number, 303-215-4515. 

In case of an emergency, call my office number and follow the directions for contacting me in urgent situations. If you are unable to reach me and feel that you cannot wait for me to return your call, please contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call.

It is important that you determine the level of emergency care that you would like to have in a therapist. My practice is not designed around 24-hour care. In the event of an emergency, it may be necessary for you to contact another health care provider. If this does not meet your needs, I would be happy to provide you with names of other therapists who may better meet your needs.

Please feel free to voice any questions or concerns that you might have, either in response to this form or at any time during our work together. I look forward to working with you.