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MANDATORY DISCLOSURE STATEMENT

In accordance with Colorado State Law, the following information is provided to all persons entering or considering entering psychotherapy.

 

I am a Licensed Professional Counselor (L.P.C.) with the Colorado Department of Regulatory Agencies. I received my Master of Arts degree in Professional Counseling from the University of Northern Colorado in 2006. My professional background includes a B.A. in Anthropology from the University of Colorado at Boulder, 10 years working with families at the City of Boulder’s Children’s Services Division, and 3 years working as a family therapist with Mental Health Partners (previously the Mental Health Center Serving Boulder and Broomfield Counties).

 

I am an independent practitioner and am not legally or professionally affiliated with any other mental health professional.

 

The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The Board of Licensed Professional Counselor Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, 303-894-7800.

 

The regulatory requirements applicable to mental health professionals are as follows:

A 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. A Licensed Social Worker must hold a masters 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 have a bachelor’s degree in behavioral health, and complete additional required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical masters degree and meet the CAC III requirements. A Registered Psychotherapist is registered with the State Board of Registered Psychotherapists, is not licensed or certified, and no degree, training or experience is required.

 

Clients Rights and Responsibilities:

A. You are entitled to receive information about me, my methods of therapy, the techniques I use, the anticipated duration of your therapy, and my fee structure. Please ask me if you would like to receive this information.

B. You may seek a second opinion from another psychotherapist, or terminate therapy at any time.

C. In a professional relationship, sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the board that licenses, registers, or certifies the licensee, registrant, or certificate holder.

D. Generally speaking, the information provided by and to you as the client during therapy sessions is legally confidential and cannot be released without the client’s consent. There are exceptions to this confidentiality, some of which are listed in section 12-43-218 of the Colorado Revised Statues and the Notice of Privacy Rights you were provided as well as other exceptions in Colorado and Federal law. If a legal exception arises during therapy, if feasible, you will be informed accordingly.

 

Disclosure regarding divorce and custody litigation:

If you are involved in divorce or custody litigation, my role as a counselor 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 or parenting time. 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 time in the best interests of the family’s children.

 

Fees:

My fee for a 50 minute therapy session is $130.00 unless another fee has been negotiated. By consenting to treatment with me you acknowledge that you are responsible for the cost of the services provided within 24 hours of the time when the service is rendered. I reserve the right to use a collection agency to collect fees that are more than 120 days past due, unless we have agreed on an alternative payment plan. Some insurance companies may cover part of your fees. You will need to determine the reimbursement policies of your insurance company. I do not file insurance claims. If you desire to file for insurance reimbursement, I will provide you a written statement for all sessions that have been paid in full. Please contact me at least 24 hours ahead of time if you need to cancel an appointment. Your appointment time is reserved for you; I cannot use it for other purposes without sufficient notice.

 

Emergencies:

You can reach me by leaving a message via either voice or text at 720-938-2793. Because there are times that I may not be available, I may not be available to provide emergency services or immediate crisis intervention. In the event of a psychiatric emergency, please call one of the following:

 

Colorado Crisis Line (24 hours): 844-493-8255

Call 911 if you or someone else is (suicidal) in immediate danger of harming yourself or someone else.

 

Your input in your treatment is invaluable to me. Please keep me informed of what you feel is helpful or not in our sessions. I welcome and encourage you to ask questions about my theory of psychotherapy, any of my policies, your bill, or any other concerns that may arise.

I HAVE READ THE PRECEDING INFORMATION, AND I UNDERSTAND MY RIGHTS AS A CLIENT. By signing this Disclosure I consent to be treated as a client of Susan Coleman, LPC.

Thank you.

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