1) Intake Form/Mental Health Form: Print and fill out one copy per
person if you are seeing me for couples counseling.

 

2) Mandatory Disclosure Form: Print and fill out one copy per couple.

 

3) Financial Policy: Print and fill out one copy per couple.

4) HIPPA Form: Print and fill out one copy per couple.

5) Consent To Use Telehealth: print and fill out one per couple.

Each client will need to complete all forms individually

*Please note: Email correspondence is not considered to be a confidential medium of communication.

Karen Wise, MS, LPC
Individual and Couples Counseling
1532 N. Emerson #302
Denver, CO 80218
kwisehealing@gmail.com
720-231-2459

 

COLORADO MANDATORY DISCLOSURE STATEMENT

1. Business : Karen Wise, MS, LPC 925 Lincoln Street, Denver, CO 80203

2. Degree : LPC (Licensed Professional Counselor) 1992 Southern Illinois University Carbondale, Masters of Counseling.

National Board Certified Counselor.  National Board Certified Counselors must finish an accredited Master’s Degree program before being allowed to take the required examination to be certified. The examination is comprehensive and passing it demonstrates a broad knowledge of the field of counseling and its theoretical applications and practices.

3. License : LPC (Licensed Professional Counselor) Colo. DORA #2650, 2 year/2000 supervised hours post graduate requirement.

4. 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.

5. The practice of licensed or registered persons in the field of psychotherapy is
regulated by the Mental Health Licensing Section of the Division of Professions and Occupations. The Board of Mental Health Licensing can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.

6. 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.  

7. In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant or certificate holder. 

8. Generally speaking, the information provided by and to 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 Statutes and the Notice of Privacy Rights you were provided as well as other exceptions in Colorado and Federal law. For example, mental health professionals are required to report child abuse to authorities. If a legal exception arises during therapy, if feasible, you will be informed accordingly. 

9. I may not be able to provide 24-hour care or after hour emergency services, therefore appropriate referrals are given to individuals in need of more intensive treatment. Examples included but are not limited to, individuals who are experiencing acute suicidal or homicidal thoughts, psychosis, or who require in-patient detoxification. In the event of an emergency please contact your local mental health center or emergency room.

10. Treatment Duration and Techniques. While it is often difficult at the outset of counseling to determine the length of treatment we will evaluate as we continue how the treatment is progressing and where we are in the process. You may end your treatment at anytime. You may seek a second opinion at any time. I will inform you what treatment techniques I will use, which will be determined by the nature of your situation. Please feel free to ask me about my treatment techniques and style at any time. 

11. Fee Agreement. The sessions are 50 minutes long and each session costs
$200.00. You will be charged for “no-show” appointments and/or if you fail to give one business day when canceling or changing an appointment. There are NO exceptions to this policy.

12. In couples therapy and/or family therapy, I may disclose information shared individually in or out of session, based upon my professional judgement, All members of the couple or family have access to the file. By signing this disclosure statement you acknowledge this and release information in this manner. 

It is important to understand that there may be a potential for stress, strain or life changes as a result of therapy. If you have any questions or concerns about this disclosure statement or would like additional information, please feel free to ask. 

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.

Karen Wise, MS, LPC
Licensed Professional Counselor #2650
1532 N. Emerson #302
Denver, CO 80218
(720) 231-2459

 

Financial Policy

 

Dear Client:
Thank you for choosing me as your therapist. The following is a statement of my
financial policy, which I require that you read, agree to and sign prior to our first session.
Please understand that payment of your sessions is part of your treatment.
1. You are responsible for all fees in full. They should be paid for at the end of the
session. I ask that you pay at the time of service unless other arrangements have
been made.
2. Acceptable methods of payment are credit card, HSA Card, Venmo and cash.
3. Cancellation of appointments must be made 24 hours in advance or you will be
charged for the missed appointment. If your session falls on a Monday you
must cancel on by the previous Friday in order not to be charged.
4. Insurance: I will provide all the necessary information on your Client Invoice so
you may submit to the insurance company for possible reimbursement. You will
be responsible for full payment of fees. The insurance company will reimburse
you according to their schedules.
It is up to you to investigate your insurance benefits and reimbursement
schedules. Dealing with insurance companies can be confusing and time
consuming. Benefits may change over time and you must remain vigilant about
your current deductible and reimbursement rates. Insurance companies may
deny or delay payment even when the paperwork is in order and submitted
properly. This requires resubmission of your receipts sometimes. Make sure to
keep copies of my client invoices in case you need to repeatedly resubmit.

 

5. Should you not pay your bill in a timely manner, I reserve the right to send your account to a collection agency. The collection agency will only receive
information relevant to collecting your fees and no information regarding the
content of your therapy will be released.

The fee charged per session will be $200.00 per 50-minute session. If you require a longer session you will be charged proportionately.

If you have any questions about this policy, please contact me immediately.

I have read, understand and agree to the provisions of this Financial Policy of Karen
Wise, MS, LPC.

Acknowledgment of Privacy Practices

My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability and Accountability Act (HIPPA). I understand that this information can and will be used to:

-Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly.

- Obtain payment from third-party payers for my health care services.

-Conduct normal health care operations such as quality assessment and improvement activities.

I have been informed of my health care providers Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information (PHI). I have been given the right to review and receive a copy of such Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices. 

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are required to abide by my restrictions.

CONSENT TO USE TELEHEALTH THROUGH ZOOM

1. I understand that my health care provider wishes me to engage in telehealth
counseling and all communications throughout Zoom are HIPPA compliant.

2. My health care provider explained to me how the video conferencing technology that will be used for counseling will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider. 

3. I understand that telehealth counseling has potential benefts including easier access to care and the convenience of meeting from a location of my choosing.

4. I understand there are potential risks to this technology, including
interruptions, unauthorized access, and technical difficulties. I understand
that my healthcare provider or I can discontinue the telehealth counseling
session if it is felt that the videoconferencing connections are not adequate
for the situation.

5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

6. Telehealth through Zoom is NOT an Emergency Service and in the event of  an emergency, I will use a phone to call 911.

7. I do not assume that my provider has access to any or all of the technical
information in the Telehealth by Zoom or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by Zoom.

8. To maintain confdentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment

By signing this form, I certify: That I have read or had this form read and/or had this form explained to me.

That I fully understand its contents including the risks and benefts of the procedure(s).

That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.