Below you will find a more detailed questionnaire about your use of substances and about any traumatic experiences.
The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of licensed psychologists, licensed clinical social workers, licensed professional counselors, and unlicensed individuals that practice psychotherapy. The agency within the department that has specific responsibility for licensed and unlicensed Psychotherapists is the State Grievance Board, 1560 Broadway, Suite 1370 Denver CO 80202, (303) 894-7766.Clients Rights and Information 1) You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy (if I can determine it), and my fee structure. I have a Master’s Degree in Counseling Psychology and am a Licensed Marriage & Family Therapist licensed in the State of Colorado (License Number 721). I am a clinical member of the American Association of Marriage and Family Therapy. I have extensive experience with couples, individuals and families both in private practice and in community mental health. 2) You can seek a second opinion from another therapist or terminate therapy at any time. 3) In a professional relationship (such as ours), sexual intimacy is never appropriate between client and therapist. If sexual intimacy occurs, it should be reported to the State Grievance Board. 4) Generally speaking, the information provided by and to a client during therapy sessions is legally confidential if the therapist is a certified school psychologist, a licensed clinical social worker, a licensed psychologist, a licensed marriage and family therapist, a licensed professional counselor, or an unlicensed psychotherapist practicing under the supervision of a licensed psychotherapist. If the information is legally confidential, the therapist cannot be forced to disclose the information without the client’s consent. There are exceptions to the general rule of legal confidentiality. These exceptions are listed in the Colorado statutes (see section 12-43-218, C.R.S., in particular). They include situations in which you are at serious risk to harm yourself or others, such as in the case of potential suicide, child abuse and neglect, or grave disability. You should be aware that, except in the case of information given to a licensed psychologist, legal confidentiality does not apply in a criminal or delinquency proceeding. There are other exceptions that I will identify to you as the situations arise during therapy.
In couples therapy, individual sessions may occur and information is kept confidential except in cases when information is shared that is damaging to the relationship (extramarital affairs, dangerous behaviors, financial abuse, etc) and is not in line with the goals of therapy. In this case, the therapist will either assist the disclosing partner to share this information in sessions or in the case it is not disclosed, therapy sessions will be terminated by the therapist.
5) Reinventing Relationships, LLC/Karen Holland is not available for emergency contact, unless arranged on a case by case basis. Should mental health emergencies occur, clients are encouraged to call 911 or go to local hospital emergency room.
6) DISCLOSURE REGARDING DIVORCE AND CUSTODY LITIGATION
If you are involved in divorce or custody litigation, my role as a therapist is not to make recommendations to the court concerning custody and 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 regarding custody. 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.
Payment is due at the time service is provided. I accept cash, check, Visa, MasterCard, Discover and American Express. Your credit card information is stored with my merchant account provider, Instamed. You can also pay via Paypal if you do not wish to share your credit card information. You may pay me directly via my PayPal ID: Karenwholland@gmail.com
Your visit has been reserved for you. 24 hours notice is required for cancellation or you may be charged the full session fee. Every client is allowed one late cancellation/no show without penalty; and emergencies, sudden illnesses and inclement weather are exempt. If you prepay for sessions, sessions are non-refundable
I have read and understand this information sheet and informed consent. I authorize counseling of the person(s) named below and agree to pay all fees and charges for such treatment. I agree to pay all charges upon the rendering of services, unless other arrangements are agreed upon. I attest that I have read this information form, that I understand the conditions as stated above, and that I consent to therapy, including evaluation, treatment and/or referral.
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