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Disclosure Statement and Informed Consent
Darren Knight-Baughman, MDiv, MEd, LPC
Darren earned a Master of Divinity from Fuller Theological Seminary and then a Master of Education, specializing in counseling and career development, from Colorado State University. Darren became an Ordained Minister through the Evangelical Covenant Church and then went on to obtain his Colorado License as a Professional Counselor (LPC Darren has provided professional counseling with Light of the Rockies since 2011, where his practice is outpatient and focused on children through adults, including couples counseling.
Edward (Eddie) Boyer, MA, LMFT, MFT-C
Eddie recently joined the Light of the Rockies Counseling Team in February 2020 and brings nearly 20 years' experience working with youth, couples, and families. His love for people and his desire to strengthen others has been a key motivating factor in his educational and career decisions. Eddie, and his wife of 18 years, have two children. Before joining Light of the Rockies, Eddie served as a youth pastor, associate pastor, outpatient therapist, college mental health counselor, and in-home family therapist. After being the lead pastor for the premarital and marriage programs at his church for 10 years, Eddie became interested in Marriage and Family Therapy. He currently is a facilitator for Prepare/Enrich, a premarital and marriage enrichment assessment, and SYMBIS premarital program, and as such enjoys using his experience working with individuals, couples, and families.
David Cartwright, MA, LPC
David holds a bachelor’s degree from Colorado Christian University in Organizational Management. He also holds a master’s degree in Biblical Studies from Cole Center for Biblical Studies in addition to his master’s degree in Counseling from Colorado Christian University. He served as a college chaplain for four years while at CCU and went on to work in an adolescent treatment center, and other mental health agencies. David has experience both in private practice and also psychiatric hospital settings. David’s work has focused on families and adolescents, couples and individuals, and also extensive group work -- and he has been a part of the therapist team at Light of the Rockies since 2017.
Jeff Englehorn, MDiv, CPC
Jeff started his educational pursuits at Seattle Pacific University where he received a Bachelor of Arts degree in English. He went on to earn a Master of Divinity, with a Family Life Education concentration from Fuller Theological Seminary. Jeff earned his Professional Coaching Certification from the Fowler Wainwright International Institute of Coaching and has served as a life coach and member of the Light of the Rockies team since 2011. Jeff works primarily with adults, specializing men’s issues (pornography addiction, sexuality issues), ADHD coaching, relationship counseling (marriage, pre-marriage), vocational transition, faith issues, and helping people identify and overcome the obstacles that hold them back from reaching their goals.
Erin Giveans, MA, LPC
Erin G. received her Bachelor of Science in Psychology from Colorado State University and went on to earn her Master of Counseling from Denver Seminary. She received her LPC through the State of Colorado and brings many years of clinical and counseling experience to the Light of the Rockies team – coming on staff in 2018. Erin has worked in a variety of therapeutic environments, including counseling clinics, a church counseling center, a psychological hospital ward, high-risk homes through a family preservation program, adolescent residential treatment centers, and in private practice counseling. Erin currently works with women, couples, teen girls, and children. Erin loves serving as a Christian counselor and uses the Bible, prayer, and the guidance of the Holy Spirit in the counseling process from the core belief that true healing comes from God.
Stephanie Harris, MA, LPCC
Stephanie started her education by earning a bachelor’s degree in Theater at Seattle Pacific University, and went on to study counseling, obtaining her master’s degree in Counseling through Colorado Christian University. With her background in the arts, Stephanie has cultivated a great empathic understanding for others and strives to be fully present in the ‘here-and-now’ with each individual. This allows for a very non-judgmental atmosphere where the individual can feel supported and heard. Stephanie has been a counselor with Light of the Rockies since 2017 and has a passion for cultivating healthy communication. She enjoys working with couples and families and also making space for individuals looking to cultivate healthier self-relationship.
Kathryn (Kat) Hughey, MA, LPC
Kathryn received a B.S. in Psychology from the University of Phoenix and an MA in Clinical Mental Health Counseling from Adams State University in Alamosa, CO. During her master’s program, she received experience working with broad populations through a practicum at Timberline Church in Ft. Collins, and also through an internship at 70 West Counseling in Wheat Ridge, CO. After graduating with her M.A. Kat worked with teenagers who had experienced trauma and exhibited high-risk behaviors at Remington House, in Ft. Collins. Kat joined the Light of the Rockies counseling team in 2018 and since then has focused her private practice on working with teenagers and their parents, and also counseling individual adults.
Kelley Johns, MA, LPC
Kelley received a BFA from the University of Colorado at Boulder and a MA in counseling from Colorado Christian University. Before joining the team at Light of the Rockies in 2017, Kelley spent time doing trauma therapy at the Medical Center of the Rockies, counseling at a local church, and in the private practice setting. Kelley has extensive experience with adolescents, young women, and the at-risk population. While much of her training is based in the Christian faith, she welcomes clients regardless of belief and background. Kelley’s therapeutic approach integrates narrative therapy, CBT, EMDR, play therapy, communication, and identity work. Kelley and the client will decide on a treatment approach based on your individual needs, current struggles, and your personal story and goals.
Ginger Masted, MA, LPC
Ginger joined Light of the Rockies in 2017 and brings 20 years of experience in working with others in their restorative journeys. She received a bachelor’s degree in Communications from the University of San Diego. She then moved to Colorado and earned her master’s degree in Counseling from Colorado Christian University. Her integrative approach includes research-based therapeutic tools and healing modalities rooted in spiritual truth. She utilizes EMDR, CBT, conflict resolution skills, communication coaching, identity exploration, spirituality, and attachment-based family therapy. Her experience includes working with children through the elderly and the unique challenges each life stage can bring. Her treatment approach is personalized to the individual or couple; paying careful consideration to the client’s goals for therapy and their story. She is deeply committed to her work and enjoys watching her client’s step into the fullness of life they were created for!
Erin Owens, MA, LPC, CAMS - II
Erin O. received a B.A. in Sociology from the University of Northern Colorado and a master’s degree in Counseling from Colorado Christian University. During her master’s program, Erin received experience working with broad populations (significant crisis and trauma work) through her practicum at the Medical Center of the Rockies. She also interned at Light of the Rockies in her last year of graduate school and has been a part of the Light of the Rockies counseling team since 2016. Erin has worked with couples, individuals, teenagers, children, and families. She has also been trained in EMDR; a specialized therapy used to treat trauma of many kinds and is a Certified Anger Management Specialist Level 2. Currently, she works with clients with a variety of struggles, including but not limited to body image and self-esteem, anxiety, eating disorders, trauma, foster and adoption struggles, anger management, marriage, and couples work, and child and adolescent issues. She has an integrated approach to counseling, providing techniques that are specialized for the needs of each client, including but not limited to Cognitive Behavioral Therapy, Psychodynamic, and Narrative Therapy.
Steve Scifres, MA, LPCC
Steve earned a Bachelor of Science degree in Psychology with a minor in Child and Family Studies and a Minor in Statistics, from the University of Wyoming. Steve then went on to earn a Master of Arts degree from the University of Northern Colorado in Marriage, Couples, and Family Counseling/Therapy. Steve began counseling with Light of the Rockies as an intern during his master’s degree coursework and has been on staff since May 2019. Through the course of the counseling program, he completed an Individual Practicum and a Marriage and Family Practicum, while under the supervision of both psychologists and multiple doctoral students. During his Internship at LOTR, Steve had the privilege of being supervised by Chris Bassett, LMFT, and LOTR Executive Director. Steve is currently pursuing his Colorado Licensed Professional Counselor Candidate license.
Kimberly Smith, MA, LPCC
Kim Smith earned a bachelor’s degree in Human Development and Family Studies from Colorado State University in 2000, and went on to earn her master’s degree in Professional Counseling from Liberty University in 2012. Kim was trained in trauma-informed care through Boise State University's Refugee Services program, as well as through foster parent training classes. As a narrative therapist, Kim believes each of our stories are complex and very telling as to who we are created to be. She also believes our essence can get lost along the way, but that it can be found again through kindness, hard work, and discovering who God says we are meant to be. Kim practices trauma-informed care, and uses many therapeutic modalities including cognitive-behavioral therapy, existential therapy, and solution-focused brief therapy -- including the use of the 12-step addiction and recovery model. Kim's work has focused on counseling couples, women and children, and is excited to have joined the Light of the Rockies team in 2020.
Andrea Post, MS, LPCC
Andrea received her bachelor’s degree from the California State University of Stanislaus and went on to earn a master’s degree in Clinical Mental Health Counseling at Walden University. Andrea originally interned at Light of the Rockies and has been a proud official member of their team since May 2019. Currently, she is pursuing her Colorado Licensure. Andrea has worked with children, teens, adult individuals, and couples, under the umbrella of non-profit organizations. She has significant experience working with individuals struggling with depression, anxiety, as well as numerous forms of abuse, including sexual, emotional, spiritual, and narcissistic abuse. Andrea utilizes various therapeutic approaches, selecting the approach that appears best suited to her client(s). Andrea has experience with Cognitive Behavioral Therapy (both CBT and REBT), Emotion-Focused Therapy, Client-Centered Therapy, and Mindfulness-Based Therapy. Andrea is happy to answer any questions relating to the therapeutic approach and process, to ensure that the client is comfortable with the counseling relationship. Andrea is driven to help her clients navigate the complicated, stressful, and often life-changing issues associated with emotional and mental help. Andrea believes in treating the whole person, and understands that our bodies, spirit, and minds are connected and impact one another.
Joyce Williams, MS, LPC
Joyce began her career by studying psychology, earning a BA in Psychology from Wright State University. She went on to study at the University of Alaska, where she received her master’s degree in Counseling Psychology. Joyce interned at the Anchorage Community Mental Health Center, then worked for five years in private practice in South Dakota. Joyce then had the opportunity to work at Overland Hills Counseling Center in Nebraska, serving as a Licensed Professional Counselor. In 1993 she relocated again to Fort Collins, Colorado, where she founded Light of the Rockies Christian Counseling Center in 1994. She served as director of Light of the Rockies from 1994-2014. Joyce enjoys working with teens, adults, couples, and families. Some of her areas of expertise include recovery from childhood abuse and trauma, eating disorders, healing relationships damaged by pornography addiction, grief, and healing from spiritual abuse.
Rachel Scheribel, Counseling Intern
Rachel is an intern here at Light of the Rockies. Her passion to help others and draw them closer to the heart of Christ is what fuels her pursuit in becoming a counselor. Rachel and her husband moved to Fort Collins in 2020 as God led them to plant a new church here in town. From her experience helping lead a college ministry within her church for three years and now serving as a pastor’s wife, Rachel understands the many challenges that people are dealing with. Seeing the many needs for a counselor within her church is what led her to pursue counseling as a career. Rachel has a Bachelor’s degree in Counseling and is finishing up her Master’s degree in Biblical Counseling from Crown College. Rachel’s warm, genuine, and non-judgemental personality allows her to connect with others on a deep level and create a space for people that feels safe. Rachel has the ability to put herself in her clients’ shoes and sit with them in their hurt, yet offer a hopeful approach for restoration and healing. Rachel’s treatment methods will be different for each client based on their unique story, history and needs. She is excited to be used by God in this new way and would love the opportunity to walk alongside you through your journey.
Brian Collison, Counseling Intern
Brian is a counseling intern at Light of the Rockies Counseling Center. He is passionate about seeing people move towards hope and healing. As a counselor Brian approaches therapy from a place of curiosity and compassion. He provides a non-judgmental space for clients to be themselves and be honest about their feelings and circumstances. Brian believes that the client is the expert of their own lives and considers it a privilege to walk alongside people as they move towards hope and healing. Brian has experienced how helpful therapy can be in his own life and looks forward to walking alongside others as they navigate their own journey.Before pursuing a career in counseling, Brian spent six years in student ministry working with youth and families. He received a MA in intercultural studies and a double major in Bible and Communications, all from Columbia International University. Brian is currently finishing his MA in Clinical Mental Health Counseling from Denver Seminary. Brian is from Pennsylvania but he and his wife of four years now call northern Colorado home.
Brian Magee, Counseling Intern
Brian strongly believes in the power and importance of the therapeutic relationship between a counselor and counselee. He strongly believes in the power of God to transform our minds through the use of Cognitive Behavioral Therapy. We are made in His image and He has great plans for us to work all things for our good and to develop us into people of character. Brian recently interned with Vail Relationship Institute in Vail, Colorado helping people with depression, anxiety, PTSD, marital problems, and the normal challenges of everyday life. One of Brian’s favorite experiences at VRI was helping lead a weekly men’s group. Brian was formerly an elder at The Orchard Church in Carbondale, Colorado where he regularly took men camping in the wilderness for time to refresh and grow with God. He is also a part of weekly small group of men who are seeking God’s wisdom and counsel in their daily lives. Brian currently owns a technology company in Glenwood Springs, Colorado but now feels God’s call to become a counselor and looks forward to helping people find the freedom and healing God has for them.
Regulation of Mental Health
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 Psychologist Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.
The regulatory requirements for mental health professionals provide that a 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 master supervision. 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 Licensed Psychologist must hold a doctorate in psychology and have one year of post-doctoral supervision. A Registered Psychotherapist is 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. A Licensed Social Worker must hold a master’s degree in social work. Certified Addiction Counselor I must be a high school graduate, complete required training hours, and 1,000 hours of supervised experience. A Certified Addiction Counselor II must complete additional required training hours and 2,000 hours of supervised experience. A Certified Addiction Counselor III must have a bachelor’s degree in behavioral health, complete additional required training hours, and have 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical master’s degree and meet the Certified Addiction Counselor III requirements.
Notice of Client Rights
Light of the Rockies Christian Counseling Center practices counseling from a Christian perspective. You are entitled to receive information from your therapist about the methods of therapy, the techniques used, the duration of your therapy (if known), and the fee structure. You can seek a second opinion from another therapist or terminate therapy at any time. 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.
Generally speaking, the information provided by and to the client during therapy sessions is legally confidential and the therapist cannot disclose or release the information 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 Statutes, and the HIPAA Notice of Privacy Rights you were provided, as well as other exceptions in Colorado and Federal law.
Confidentiality Limitations1) If you threaten grave bodily harm or death to another person, your counselor is required by law to take reasonable care to protect that other person. This may include telling the intended victim and/or appropriate law enforcement agencies. 2) If you indicate a serious intention to harm yourself, your counselor will take steps to prevent such harm from occurring. 3) If a court order is issued, your counselor is required by law to provide the information specifically described by the court (unless an appeal is filed). 4) If you share information about a child or children that have been or are currently being abused or neglected, or if an adult reports abuse by someone who is in a position of trust with any child currently under eighteen years of age, your counselor is required by law to report this to the Department of Social Services or the local law enforcement agency. If you share information about an elder or elders (70 years of age or older) that have been or are currently being abused or neglected, or if an adult reports elder abuse by someone who in is in a position of trust with an elder or elders (70 years of age or older), your counselor is required by law to report this to the Department of Social Services or the local law enforcement agency. 5) If you pose a threat to national security. If a legal exception arises during therapy, if feasible, you will be informed accordingly. In order for us to release information pertaining to individuals participating in couples or family therapy all adults involved in therapy must consent to the release of information. Additionally, information shared by individuals may be disclosed in participating in couples or family therapy at the discretion of the therapist. You are encouraged to discuss any reservations with Light of the Rockies. Emergency SituationsIn case of an emergency outside of normal business hours please contact:Colorado Crisis Services call 1-844-493-TALK (8255) or text TALK to 38255Summit Stone Community Crisis Clinic call (970) 494-4200 or visit 1217 Riverside Ave in Fort CollinsCall 911 or visit the nearest hospital emergency room I have read the preceding information, it has also been provided verbally, and I understand my rights as a client or as the client’s responsible party and I consent to enter treatment, for either myself or my child, with Light of the Rockies.
HIPAA Notice of Privacy Rights
Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
“PHI” refers to information in your health record that could identify you.
“Treatment, Payment, and Health Care Operations”
– Treatment is when I provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychotherapist.
– Payment is when I obtain reimbursement for your healthcare. Examples are when I disclose your PHI to your health insurer for reimbursement for health care or to determine eligibility or coverage.
– Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits, administrative services, case management, and care coordination.
“Use” applies only to activities within my [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure” applies to activities outside of my [office, clinic, practice group, etc.] such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment, or health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.
You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, the law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse – If I have reasonable cause to know or suspect that a child has been subjected to abuse or neglect, I must immediately report this to the appropriate authorities.
Adult and Domestic Abuse – If I have reasonable cause to believe that an at-risk adult has been mistreated, self-neglected, or financially exploited and is at imminent risk of mistreatment, self-neglect, or financial exploitation, then I must report this belief to the appropriate authorities.
Health Oversight Activities – If the Grievance Board for Unlicensed Psychotherapists or an authorized professional review committee is reviewing my services; I may disclose PHI to that board or committee.
Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or the records thereof, such information is privileged under state law, and I will not release information without your written authorization or court order. The privileged does not apply when you are being evaluated or a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.
Serious Threat to Health or Safety – If you communicate to be a serious threat of imminent physical violence against a specific person or persons, I have a duty to notify any person or persons specifically threatened, as well as a duty to notify an appropriate law enforcement agency or by taking other appropriate action. If I believe that you are at imminent risk of inflicting serious harm on yourself, I may disclose information necessary to protect you. In either case, I may disclose information in order to initiate hospitalization.
Worker’s Compensation – I may disclose PHI as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provided benefits for work-related injuries or illness without regard to fault.
IV. Patient’s Rights and Psychotherapist’s Duties
Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information regarding you. However, I am not required to agree to a restriction you request.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. On your request, I will send your bills to another address.)
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.
Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.
Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, I will discuss with you the details of the accounting process.
Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
If I revise my policies and procedures, I will notify my client by mail.
V. Questions and Complaints
If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact Light of the Rockies at (970) 484-1735.
If you believe that your privacy rights have been violated and wish to file a complaint with me or my office, you may send your written complaint to:
Light of the Rockies
5236 Strauss Cabin Rd
Fort Collins, CO 80528
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.
You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
This notice will go into effect on September 1st, 2007.
I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by mail within ten business days prior to changes.
VII. Client Signature
I acknowledge that I have received and reviewed a copy of Light of the Rockies HIPAA Notice of Privacy Rights.
Light of the Rockies Policies
Payment and Fees
Payment is due at the time of service. Cash or check is preferred, but Visa, Mastercard, and Discover are also accepted. American Express is not accepted at this time. HSA and FSA benefits are accepted. There is a $20 fee on all returned checks. The standard fee is $140 unless the client chooses to use the Sliding Fee Scale or Insurance. The client will be charged a fee for phone consultations and written correspondences lasting longer than five minutes. If a court appearance or deposition is required, additional information is available on a separate document. Light of the Rockies will charge the card on file for all professional fees.
Cancelations and Late or Missed Appointments
If the client needs to cancel their appointment, Light of the Rockies requests that the client give advanced notice greater than 24 hours if possible. This allows the counselor to make that time available for other clients. Cancelations must be requested at least 24 hours in advance for a one-hour session and at least one week in advance for a two-hour session. If the client is unable to reschedule within the counselor’s availability for the week, then the client is responsible for the standard rate. Alternatively, if the client is unable to come into the office, telehealth can be made available. If a client is late by 10 minutes or misses an appointment without any prior notification, then the client will be responsible for the standard rate. If more than 2 late cancelations or missed appointments occur within 6 months, Light of the Rockies may terminate treatment. Emergency situations will be handled on a case by case bases and may require additional documentation. Insurance does not reimburse for canceled or missed appointments and may not cover telehealth. Light of the Rockies will charge the card on file for late cancellations or missed appointments.
Scholarships may be approved for individuals experiencing outstanding finical circumstances that impact their ability to seek or continue treatment at Light of the Rockies. If approved, providing funds are available, the client may receive a partial scholarship. The client is responsible for all remaining costs of services provided by Light of the Rockies.
Sliding Fee Scale
The client may qualify for the Sliding Fee Scale if their annual household income is less than $120,000. The client is responsible for providing income verification documents to Light of the Rockies annually. Acceptable income verification documents include (1) Three Months of Paystubs, (2) IRS W2 Tax Forms, or (3) IRS 1040 or Schedule C Tax Forms. The client’s annual household income must be verified by Light of the Rockies before the Sliding Fee Scale rate may be applied to the client’s future sessions. Clients using the Sliding Fee Scale are not eligible for out of network Superbills.
The client, regardless of insurance coverage, is responsible for the cost of all services provided by Light of the Rockies. It is the client’s responsibility to understand their eligibility and benefits specific to mental health. If the counselor is an out-of-network provider, the client will be charged the standard fee and a monthly Superbill will be provided at the request of the client unless prior arrangements have been approved by Light of the Rockies. If the counselor is an in-network provider, it is the client’s responsibility to provide their insurance information to Light of the Rockies. The client is required to pay the full contracted rate until Light of the Rockies receives an Explanation of Benefits verifying the client’s coverage. If a refund is due, then a credit will be applied to the client’s account unless a direct refund is requested. If required by the client’s insurance, the client is responsible to request and submit a referral or pre-authorization information to Light of the Rockies prior to their first appointment. If a client is insured by Medicaid, the client is required to find a community sponsor who will make payments on behalf of the client and submit the Community Sponsorship Agreement to Light of the Rockies prior to their first appointment. Light of the Rockies will charge the card on file for insurance claim responsibilities, adjustments, or denials.
I acknowledge that I have read and understood the preceding information and agree to the Light of the Rockies Policies and that I am responsible for the payment of all professional fees. Additionally, if using insurance, I authorize the release of any relevant information requested by my insurance company regarding diagnosis, treatment, and clinical summaries and I request payment of insurance benefits to Light of the Rockies.
Credit Card Authorization
Light of the Rockies requires that all clients keep an active debit or credit card is on file unless prior arrangements have been approved. We will NOT charge this card without your permission, EXCEPT in the following cases:
I authorize Light of the Rockies to keep this card on file and to charge full or partial fees to this card for services provided. I agree to notify Light of the Rockies about any changes to the card or billing information. I understand that this authorization is valid until canceled in writing. I agree that if I have any problems or questions regarding charges to my account, I will contact Light of the Rockies for assistance. I agree that I will not dispute any charges with my credit card company until attempting to rectify the situation with Light of the Rockies. Please notify the office, prior to your appointment, if you prefer to pay with cash or check.
You must submit valid credit card information by completing the form below or calling our office at (970) 484-1735.
Download the file to your computer and open the file in a PDF viewer (e.g. Adobe or Preview) before you fill it out. Remember to save the file before uploading it.
Click Here to Download the Credit Card Authorization Form
Light of the Rockies requires a copy of your license and both sides of your insurance card before your first appointment.
Light of the Rockies requires one of the following documents to verify income information before your first appointment:
1) Three Months of Paystubs 2) IRS W2 Tax Forms 3) IRS 1040 or Schedule C Tax Forms
Initial Intake - Adult
This questionnaire will be kept in your clinical record.
All responses are optional and confidential.
Mental Health History
During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems?
Please mark your response with an X in the corresponding box