DISCLOSURE STATEMENT, CLIENT RIGHTS and AGREEMENT FOR COUNSELING SERVICES Welcome. This statement is being provided so that you are aware of your rights as a psychotherapy client. This document also includes our agreement for counseling services. I ask that you bring up any questions or concerns you may have about what is written here. Once you have fully understood the following, I will ask you to sign it, and a copy will be given to you. Education and Credentials: B.S., Sociology, Northern Arizona University, 1984 M.A., Counseling Psychology and Counselor Education, University of Colorado-Denver, 2006 Licensed Professional Counselor, Colorado, #5591 National Board Certified Counselor American Counseling Association Chi Sigma Iota, academic honor society Therapeutic Approach: My approach with clients is based on balancing acceptance with change. The work involves improving your capacity to experience each moment more fully and to act consistent with what really matters to you. I may draw upon various approaches, including cognitive-behavioral, mindfulness-based, person-centered, and include psychoeducation in areas such as communication, parenting and relationships. You are invited to, at any time, ask questions about what we are doing and the reasons for the particular interventions. This is your process and investment. I am ethically required to inform you of the following: Regulations: The Colorado Department of Regulatory Agencies 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 the department that has responsibility for licensed and unlicensed psychotherapists is the State Grievance Board, 1560 Broadway, Suite 1350, Denver, Colorado, 80202, phone number (303)894-7800. Client Rights: 1. You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of therapy and my fee structure. 2. You may seek a second opinion from another therapist at any time. 3. In a professional relationship, such as ours, sexual intimacy between therapist and the client is never appropriate and is also illegal in Colorado. If sexual intimacy occurs between a counselor and client, it should be reported to the State Grievance Board immediately.
4. 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 clinical social worker, a licensed psychologist, a licensed professional counselor or an unlicensed psychotherapist practicing under the supervision of a licensed psychotherapist. If the information is legally confidential, the therapist cannot be forced to disclose the information without the clientʼs consent. 5. Information disclosed to a licensed clinical social worker, a licensed marriage and family therapist, a licensed professional counselor, a licensed psychologist or an unlicensed psychotherapist 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. Confidentiality Exceptions: There are exceptions to the general rule of legal confidentiality. These exceptions are listed in the Colorado statutes (see section 12-43-218 C.R.S.). These exceptions include, but are not limited to: intent to harm yourself or others; information regarding abuse or suspected abuse of children, elderly or others unable to care for themselves; subpoenaed testimony in criminal cases and orders to violate privileges by judges in child custody, divorce and other court cases. You should be aware that, except in the case of information given to a licensed psychologist, legal confidentiality does not apply in criminal or delinquency proceedings, except as provided in section 13-90-107 C.R.S. There are other exceptions that I will identify to you as the situations arise during therapy. Fees and Policies: My fee is $75.00 for a clinical hour, which is 50 minutes. Accepted methods of payment are checks, credit card or cash. Checks are to be made out to Caroline Dohm, MA, LPC. If the appointment is not kept or is cancelled with less than 24 hoursʼ advance notice, the full fee for services will be charged. Discuss with me the circumstances surrounding a need to make a late cancellation or not keep an appointment, as it is understandable that emergencies do arise. If I am subpoenaed by the court, court testimony on your behalf is charged at a higher rate of $100.00 per hour, including: testimony-related matters such as case research, report writing, travel, deposition, actual testimony and cross examination time and courtroom waiting time. Health Insurance: I am a provider for a limited number of health insurance companies. If your company is not one of them, you can check with your insurance to see if it will pay for your counseling time with me. I will supply you with an invoice for my services with the standard diagnostic and procedure codes for billing purposes, the times we met, my charges and your payments. You can use this to apply for reimbursement.
AGREEMENT FOR COUNSELING SERVICES: I, the client, understand and agree that: 1. No specific promises have been made to me by my counselor about the results of treatment, the effectiveness of the procedures used by this counselor or the number of sessions necessary for therapy to be effective. 2. Caroline Dohm is not a crisis therapist. If I have a life threatening emergency, I will need to call the Suicide and Crisis Hotline (970)241-6022; the Domestic Violence or Sexual Assault crisis line (970)241-6704; the police (911); or go immediately to the nearest emergency room. I understand that if my counselor thinks I need more intensive services, I will be referred to a therapist or organization that has the ability to provide treatment to meet those needs. 3. Caroline Dohm provides non-emergency psychotherapeutic services by scheduled appointment. If she believes my psychological issues are above her level of competence or outside her scope of practice, she is legally required to refer, terminate or consult. 4. I understand that I am legally responsible for payment for my psychotherapy services. I understand that if I do not give 24 hoursʼ prior notice of cancellation to my counselor, I will be charged the full fee. CLIENT ACKNOWLEDGEMENT, CONSENT AND AGREEMENT: I have read the preceding information and understand my rights and responsibilities as a client. I consent to treatment. __________________________________________________________________________ Client signature" " " " " " " " " Date __________________________________________________________________________ Client printed name"" __________________________________________________________________________ Counselor" " " " " " " " " " Date Copy given to client Copy kept in records
