DISCLOSURE, TREATMENT, AND FEE AGREEMENT

Jeffrey Nelson, LCSW
1805 S. Bellaire St., Suite 219
Denver, Colorado 80222
Phone: 303-408-9658

Degrees and Credentials
Bachelors of Science in Social Work; Metropolitan State College of Denver (1996) Masters in Social Work; University of Denver (1997), Licensed Clinical Social Worker (2000) Colorado License #: 992452; Licensed Clinical Social Worker, (2022) Kentucky License #: 257459

Professional Affiliations:
Colorado Community College System (Adjunct Faculty)
Jefferson County Recovery Court (Oversight Committee)

Regulation of Psychotherapy Practice
The Colorado State Department of Regulatory Agencies regulates the practice of psychotherapy for licensed and registered psychotherapists. Concerns regarding the practice of psychotherapy may be directed to the Department of Regulatory Agencies, Mental Health Section, 1560 Broadway, Suite #1340, Denver, Colorado 80202; Ph: (303) 894-7800.

Client Rights and Important Information
Method of Treatment: You are entitled to receive information about the methods of treatment, techniques used, duration of therapy if known and the fee structure. At any time you may seek a second opinion or terminate treatment. Please be advised that in a professional relationship, sexual intimacy is never appropriate and should be reported to the Department of Regulatory Agencies.

Sessions and Fees: Sessions are billed by the 45-minute hour at a rate of $140 per session (initial evaluation session is $185), with a co-pay/fee amount of $______. Payment for each session is due at the time of each therapy session. If you carry mental health insurance, arrangements will be made for payment of services from the insurance company and you held will beresponsiblefor deductibles, co-payments, non-covered services, or unpaid balances. You will be billed $60 to $140 for missed sessions unless you cancel at least 24 hours prior to your scheduled session. There is a $39 processing fee for checks returned "non-sufficient funds.' Phone calls over 5" long are charged at $140.00/hour at 15" increments. Forensic Work: Court testimony is not provided by Jeff Nelson, LCSW, (this is not my role); report writing is charged at 3 times my normal rate (or $420.00/hour)

Confidentiality: Sessions are by law, confidential. Information regarding treatment may be shared with a third party only withwritten consent from the client. Exceptions to confidentiality include when the client is in imminent danger of harmingself or others, or when child or elder abuse is suspected. In the case of working with minors, legal guardians will know about the treatment, though privacy will be respected as much as possible. When treating couples and/or families, confidentiality among couples and family members is not a guarantee.

Emergencies: In a mental health emergency dial 911or go to your nearest urgent care or emergency center. Calling the therapist regarding an urgent matter is available provided your call back number is not blocked. Calls are returned as soon as possible.

— A 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 post-doctoral supervision, and pass an examination in psychology.

I understand that mental health and medical records may not be maintained after 7 years. I understand and agree to the conditions stated above, including policies regarding fees, insurance, cancellations, confidentiality, crisis coverage, and client rights. I have read the preceding information; it has also been provided verbally, and I understand my rights as a client/patient or as the client's responsible party.

Client/Patient Signature (Parent Signature if Client is under age 18)