DISCLOSURE AND INFORMED CONSENT
McAllaster & Associates Counseling, LLC
Amy McAllaster, MA, LPC
5777 S Rapp Street, Littleton, CO 80120
(303) 513-7822
Welcome to my practice. My hope is that you will experience counseling as a place of respect, understanding, learning, and calm. As you read through the following information, please write down any questions you might have as you will have an opportunity to discuss these during your first appointment. It is very important that we discuss any concerns you have related to anything you read on these pages.As you read through thisplease initial where indicated and sign at the bottom of the form.
Qualifications, Credentials, Licensing, Degrees, and Experience
I am licensed by the State of Colorado for Professional Counseling; License #4155. I hold a Master’s Degree in Marriage and Family Therapy and have been in professional private practice for 16 years, with an additional 2 years of crisis counseling experience. I have counseled in a group counseling setting and a private practice setting. I work with children, adolescents, and adults on an individual, couple, family, and group counseling basis. It is important for you to know that my practice and my professional behavior are overseen by the Colorado Department of Regulatory Agencies, 1560 Broadway, Suite 1350, Denver, CO 80202. They can be reached at (303) 894-7800. I am a member of the American Association of Christian Counselors (AACC) and the American Counseling Association (ACA). In addition to being governed by the Mental Health Code of Colorado, as a member of these organizations, I am governed by their separate and additional ethical codes. You also need to know the Regulatory Requirements for Mental Health Professionals in Colorado in compliance with 12-43-214 (1)(b)(I), C.R.S. includes the following: 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 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-masters 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 post-doctoral practice, and pass an exam 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.
Method of Treatment
It is my desire to provide the highest quality clinical counseling in a safe, comfortable, respectful environment. I take a positive approach in therapy, believing that people are resilient and have tremendous resources to address life’s situations. My role is to assist you in understanding the dynamics of your situation, relationship(s), or issue, and to help you to utilize your particular strengths to resolve the issues.Therefore, counseling methods will include but are not limited to Person-Centered Therapy, Solution-Focused Therapy, Cognitive-Behavioral Therapy,Dialectical Behavior Therapy, Expressive Therapies, Play Therapy, and Family Therapy, all with an emphasis on relational dynamics. While I respect the values, beliefs, and opinions of each of my clients I also offer Faith-Based counseling should you desire it.
Nature of Relationship
Part of my role as counselor is to help and protect you, the client, from harm or abuse during our sessions. Therefore, it is important for you to know that your relationship with me is a professional and therapeutic relationship only. To protect the nature of this relationship it is imperative that I not have any other type of relationship with you. Social and/or business relationships undermine the effectiveness of the therapeutic relationship. If I should see you outside of my counseling office I will not initiate conversation to protect the confidentiality and privacy of our communication. Should you desire to initiate conversation or contact I am happy to reciprocate. In a professional relationship sexual intimacy is never appropriate and is an abuse of your vulnerability as a client. You, the client, should report all incidents of sexual intimacy with a professional counselor to the Colorado State Board of Professional Counselors.
Goals, Risks, and Benefits
Although benefits are expected, and often seen, from counseling, specific outcomes are not guaranteed. The goal of counseling is to confront issues and emotions together and to work through them over time, resulting in resolution of those issues. However, there is always a risk of emotional side effects from counseling as it oftenbrings up painful emotions and sometimes symptoms worsen before they get better. I encourage you to ask questions regarding the goals, risks, benefits, or outcomes of counseling. At all times you maintain control of yourself and can make decisions regarding your care. You have the right to seek a second opinion or to terminate counseling at any time.
Referrals
Should I/we decide that a referral for another counselor or helping professional is needed, names and numbers will be provided. A verbal exploration of alternatives to counseling will also be made available upon request. You, the client, are responsible for contacting and evaluating those referrals and/or alternatives.
Length of Treatment
Length of treatment will vary and will be determined by you, the client, and myself, the counselor, together. Each individual and relationship has unique strengths and weaknesses, and each problem is different from the next. The goal is that each client will terminate counseling in a timely manner, eliminating unnecessary use of time or financial resources. Groups will have a predetermined number of sessions, usually six to ten.
Confidentiality
All communication between you, the client, and myself, the counselor, becomes part of your clinical record and is legally confidential. I will keep all information you share with me private according to the laws and ethics of the State of Colorado Mental Health Statute. However, Colorado law does specify some exceptions to this rule. The major exceptions include, but are not limited to:
- I, the counselor, determine that you, the client, are a danger to yourself or someone else
- You, the client, disclose abuse, harm, neglect or exploitation of a child, elderly, or disabled person
- You, the client, authorize the counselor to release records
- I, the counselor, am required by the court to disclose information for criminal or delinquency proceedings or by law for other reasons
- If you pay by credit card your full name, credit card number, and expiration date will be disclosed to the credit card company
In the case of marriage or family counseling, there is limited confidentiality, meaning the confidentiality belongs to the relationship and not the individual. In family and group work, confidentiality cannot be guaranteed and limits will be discussed with you, the client. I, the counselor, cannot guarantee and am not responsible for the confidentiality of your records after you, the client, file for reimbursement with your insurance company. Name, address, diagnosis, and service codes are all included in your receipt and should be considered when filing for reimbursement. I am not responsible for any breach of confidentiality that should occur as a result of your submitting your counseling receipts and the information contained therein to the insurance company or its employees. No audio taping or recording of sessions is allowed by client or counselor. ______Initials
Minors & Parents
Patients under 15 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records unless I decide that such access is likely to harm the child. Because privacy in therapy is critical for successful progress, especially with adolescents, it is sometimes my policy to request an agreement from parents releasing their access to their child’s records. If they agree, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. Any other communication will require the child’s authorization, unless I feel that that child is in danger or is a danger to someone else. In those cases I will notify the parents of my concern. Before giving parents any information I will discuss the matter with the child, if possible. ______Initials
HIPAA and Privacy
You have privacy rights under a federal law that protects your health information. You have the right to:
- Ask to see and get a copy of your medical records. In the case that I feel you or someone else will be harmed by information contained in your records I have the right to refuse disclosure. Records will be given to you within 30 days upon receipt of a written, signed, and dated request from you. Fees are $110 for copies of records unrelated to a court proceeding. Please see “Legal Fees” section below for information regarding court ordered records and fees.
- Request corrections or changes be made to your health information. Requests for change may be denied, with a written notice to you of the reason for denial. If changes to your record are appropriate, they will take place within 60 days upon receipt of a written, signed and dated request for changes.
- Receive a notice telling you how your health information is shared and used
- Decide whether to give your permission before health information is shared or used for certain purposes
- If you feel your health information is not being protected or your rights are being denied, complaints should be made in writing to: Amy McAllaster, MA, LPC, 5777 S Rapp Street, Littleton, Colorado 80120. You may also file a complaint with: Health and Human Services or the Office of Civil Rights. The complaints should be directed to the Office for Civil Rights, U.S. Department of Health & Human Services, 1961 Stout Street - Room 1426, Denver, CO 80294,(303) 844-2024; (303) 844-3439 (TDD), (303) 844-2025 FAX. You may also, if you wish, file a complaint with the Colorado Department of Regulatory Agencies, 1560 Broadway, Suite 1350, Denver, CO80202. They can be reached at (303) 894-7800. ______Initials
I have the right, the legal and/or ethical dutyto disclose your health information without your consent for the following situations:
- For treatment, payment, and health care operations as defined by HIPAA
- For the following additional purposes as defined by the HIPAA: as required by lawfor judicial and administrative proceedings (Court order or subpoena), for public health reporting activities, in the case of abuse, harm, neglect, or domestic violence; for health oversight activities; for law enforcement purposes; in the event of serious threat to health or safety; for essential government functions; and for workers’ compensation.
- To defend myself in malpractice hearings or legal hearings brought on by you, for Health and Human Services or Office of Civil Rights Privacy Hearings, or for the lawful oversight of myself as a practitioner by the State of Colorado Board of Licensed Professional Counselors Examiners.
For more detailed explanations, please ask to receive a copy of the HIPAA Rule as published by the Office of Civil Rights. I will be glad to provide you with the additional information. _____Initials
Legal Fees
If I amcourt-ordered to testify in any court-related proceeding or court-ordered to produce records for a court related issue, I will produce the requested information only as I am required by law. You, the client, will be responsible for fees in the amount of $300/hour for the following court-related activities: productions of any form or report related to client records, travel, preparation, review, wait time and actual time of any deposition, court hearing or proceeding. You, the client, will also be responsible for a retainer fee in the amount of $2,000.00. All fees will due 3 business days prior to any court related activity.
Supervision and Consultation
I am a LPC Supervisor, meaning that I supervise students who are working toward licensure in Professional Counseling in the State of Colorado. I also participate in professional consultation and sometimes consult with other professionals or experts on treatment issues. Therefore upon occasion it may be necessary for me, the counselor, to discuss your case with a student, another therapist, pediatrician, family physician, psychiatrist, supervisor, supervisee,or other helping professional.All of the students and/or professionals and experts I supervise/consult with are under the same legal and ethical requirements and your confidentiality will be protected according to the laws and statutes of the Mental Health Code of Colorado. If you have any questions regarding this practice you have the right to inquire at any time.
Contacting Me
Phone contact:
You can contact me by leaving a message on my office line at ____(303) 513-7822___. I am not usually available immediately by telephone. When I am in my office, I do not answer the phone if I am with a client, and my telephone is answered by a voicemail that I check a number of times per day. I will make every effort to return your phone call within 24-48 hours with the exception of holidays and weekends. On holidays and weekends I will return your phone call the next day I am back in the office. Please note that anything beyond a 5 minute phone call will be charged to you on a prorated basis at the regular in-office rate. If you are difficult to reach please inform me of some times that you are available and multiple phone numbers where I can reach you. Phone sessions are available by schedule if you should desire to use telephone for treatment. ______Initials
Email/Text Contact:
I have an email account that you can access through my website at Please not that I only use email as a way to SCHEDULE appointments with clients who prefer email. Email/texting are not acceptable forms of communication to cancel appointments with me. If you need to cancel please leave me a message on my office telephone line. In addition, to protect your privacy I do not use email or texting to discuss clinical matters or answer clinical questions. Finally, email and texting are not acceptable ways to communicate clinical emergencies. Please refer to emergency section for discussion on how to handle emergencies. Please also understand that while my email server is confidential and secure, as soon as you receive the email, I cannot guarantee confidentiality from that point forward. ______Initials
Emergencies
It is important for you to decide the level of emergency care that you would like to have in a therapist. I do not provide 24-hour care. If you are having an emergency and cannot wait for me to return your phone call, you may call 911, go to the nearest Emergency Room, or call the local Police Department. It is your responsibility to seek the appropriate resources in emergency situations. If at any point during our work together we determine that you should need a higher level of care, I will provide you with the names of therapists and treatment centers that provide 24 hour care. ______Initials
While I do not anticipate any lengthy interruptions to your counseling, there may be times, due to illness, injury, or unexpected emergencies that I will not be able to counsel you at the scheduled date and time. If this should occur, I will attempt to contact you, alert you of the situation, and will provide alternative times or days for your session, if possible. In addition, during vacations or holidays, you and I will develop a plan for your well-being if requested. The name(s), and number(s), of another helping professional will be provided upon request for times I am away from the office. ______Initials
Fees
Counseling sessions will be 45-50 minutes long at a cost of $125. (FOR GROUPS ONLY: _____sessions for a total of ______). Fees may be paid by cash, check, Mastercard, Visa, or Discover. Payment is due in full at each session, and payment for all group sessions is due at the initial session. Insurance may reimburse all or part of the counseling fees. I do not file your insurance claims for you; however, documentation is provided should you choose to file with your insurance. Keep your receipts in a safe place for insurance/tax purposes. If copies of receipts are needed, a one-week time period is necessary for me to produce them for you. ______Initials