PROFESSIONAL TRAINING AND CERTIFICATION
I am a Certified Hypnotherapist. I am certified through the National Guild of Hypnotists. I received my B.A. from Metropolitan State University in Behavioral Science with an emphasis in Psychology. I received my Hypnotherapy training from Eastburn Hypnotherapy Center. I am trained in Co-Active Life Coaching from the Coaches Training Institute, Evolutionary Astrology from Steven Forrest Astrology, Past Life and Between Lives Soul Regression from Dr. Linda Backman and the Ravenheart Center.
YOUR RIGHTS AS A CLIENT
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 Registered Psychotherapists 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. A Certified Addiction Counselor I (CAC I) must be a high school graduate or equivalent, complete required training hours and 1,000 hours of supervised experience. A Certified Addiction Counselor II (CAC II) must be a high school graduate or equivalent, complete the CAC I requirements, and obtain additional required training hours, 2,000 additional hours of supervised experience, and pass a national exam. A Certified Addiction Counselor III (CAC III) must have a bachelor’s degree in behavioral health, complete CAC II requirements, and complete additional required training hours, 2,000 additional hours of supervised experience, and pass a national exam. A Licensed Addiction Counselor must have a clinical master’s degree, meet the CAC III requirements, and pass a national exam. A Licensed Social Worker must hold a master’s degree from a graduate school of social work and pass an examination in social work. A Licensed Clinical Social Worker must hold a master’s or doctorate degree from a graduate school of social work, practiced as a social worker for at least two years, and pass an examination 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 Licensed Marriage and Family Therapist must hold a master’s or doctoral degree in marriage and family counseling, have at least two years post-master’s or one-year post-doctoral practice, and pass an exam in marriage and family therapy. A Licensed Professional
Counselor must hold a master’s or doctoral degree in professional counseling, have at least two years post-master’s or one-year postdoctoral practice, and pass an exam in in professional counseling. A Licensed Psychologist must hold a doctorate degree in psychology, have one year of postdoctoral supervision, and pass an examination in psychology. You are entitled to receive information about the methods of therapy, the techniques used, the duration of therapy, if known, and the fee structure. You
are also to be informed of therapist’s degrees, credentials, and licenses. You may seek a second opinion from another therapist or terminate therapy at any time. You should know that in a professional relationship, sexual intimacy is never appropriate, and should be reported to the Grievance Board.
CONFIDENTIALITY
Generally speaking, the information provided by the client during therapy sessions is legally confidential, and cannot be released without the client’s consent. except as provided in § 12- 43-218 and except for certain legal exceptions that will be identified by the licensee, registrant, or certificate holder should any such situation arise during therapy. If a legal exception arises during therapy, if feasible, you will be informed accordingly. The Mental Health Practice Act (CRS 12-43- 101, et seq.) is available at: http://www.dora.state.co.us/mental-health/Statute.pdf Matters regarding your therapy will be kept confidential except in the following circumstances: you sign a release of information giving permission to release information to a specific individual or agency; child abuse; client is in imminent danger to self or others; subpoena of records. I may also consult with a supervisor or other colleagues, but in this circumstance, clients are not identified by name. Your signature constitutes your giving your permission for such consultation.
MY AVAILABILITY AND MESSAGING SERVICES
I am available to receive your calls/texts during most normal business hours. If I am in a session, you will reach my voicemail. I pick up messages regularly. If you have a major emergency and cannot reach me, you may need to call 911 or seek help at a mental health center or hospital. There is no charge for brief phone calls, texts, or email. Calls lasting longer than ten minutes will generally be charged to the client on a pro-rated basis.
TERMINATION OF THERAPY
It is always your right to terminate therapy at any time. However, I strongly encourage you to discuss this decision with me. It has been my experience that, particularly in a therapeutic relationship of any length, termination is a very important process. If I see you as approaching readiness to leave therapy, I will certainly discuss this with you. I will also discuss your progress and status on an ongoing basis.
FEES AND PAYMENTS
The charge for hypnotherapy can be per session, per hour, or per package. The length of a session may vary, but the fee remains the same. Packages will save money and must be paid upfront to get the benefit. The fee for your session will be made clear before your session begins. Payment is due at the beginning of each session. Non-payment automatically waives your rights to confidentiality. If paying with credit card via PayPal or other credit payment option, there may be a transaction fee that will be charged to the client in addition to regular fee. Multiple payments options are available that will not require an additional fee.
ADDITIONAL INFORMATION If you have any questions or would like any additional information, please feel free to ask. You are entitled to a copy of this form.
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.