Disclosure Statement and Informed Consent-Intern
Intern Therapist Name:______303-756-9052 x_____
University/Degree: ______(in progress)
Supervisor/Degree:______License #:______
I am a therapist-in-training/intern, and will be at Maria Droste Counseling Center from: ______to ______.
The practice of licensed, registered, or unlicensed persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Professions and Occupations at 1560 Broadway Street; Suite 1350; Denver, CO 80202; 303-894-7800.
The Board of Licensed Professional Counselor Examiners
The Board of Marriage and Family Therapists Examiners
The Board of Psychologist Examiners
The Board of Social Work Examiners
The Board of Registered Psychotherapists (unlicensed psychotherapists)
Colorado Department of Human Services, Division of Behavioral Health 3824 W. Princeton Circle, Denver, CO 80236 (303) 866-7400 for substance use treatment
A Licensed Clinical Social Worker (LCSW), a Licensed Marriage and Family Therapist (LMFT), or a Licensed Professional Counselor (LPC) must hold a masters degree in their profession and have two years of post-masters supervision. A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision. A Licensed Social Worker (LSW) must hold a masters degree in social work. A psychologist candidate, a marriage and family therapist candidate, or a licensed professional counselor candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure. A Certified Addiction Counselor I (CAC I) must be a high school graduate, and complete both the required training hours and 1000 hours of supervised experience. A CAC II must complete additional required trainings hours and 2,000 hours of supervised experience. A CAC III must have a bachelor’s degree in behavioral health, and complete both additional the required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor (LAC) must have a clinical masters degree and meet the CAC III requirements. A Registered Psychotherapist is registered with the State Board of Registered Psychotherapists and is not licensed or certified; no degree, training or experience is required. An intern therapist must be a student in good standing, enrolled in a counseling or social work training graduate degree program at an accredited college/university, and meet the Internship Requirements at Maria Droste Counseling Center.
CONFIDENTIALITY:
The information provided by you during therapy is legally confidential except as required by law. There are some exceptions to the rule of confidentiality. In general, these exceptions include:
1.Reporting cases in which:
- the client may present a danger to self or others
- there is an indication of child or elder abuse and/or neglect
- threat by a prospective or actual client to jeopardize an entity that could potentially result in the physical harm of others
- a court order
2.If an above mentioned legal exception arises regarding confidentiality and if feasible, you will be informed accordingly.
3.All intern therapists report to a supervisor as a trainee under supervision. Your intern therapist will discuss your treatment with supervisors, and/or Maria Droste Counseling Center staff under the provisions of the student/supervisory relationship. Information from psychotherapy sessions may be used for educational purposes. As part of their education and training, your intern therapist may discuss their clients in group supervision, case conferences, consultation and/or student review. All material is reported anonymously and personal confidentiality is strictly maintained.
CLIENT RIGHTS:
You are entitled to receive information about methods of therapy, the techniques used, the duration of therapy if known, and the fee. You may seek a second opinion from another therapist and may terminate therapy at any time. In a professional therapy relationship, sexual intimacy is never appropriate and is illegal in Colorado. It should be reported to the appropriate Board or Division listed above.
APPOINTMENTS:
Therapy sessions are 50 minutes. This time is reserved for you. In the case that you need to cancel or reschedule an appointment, 24-hour advance notice is required. With less than 24 hours notice, you will be charged the full amount for the session. This will be your responsibility and cannot be charged to insurance.
FEE:
Our full fee for a 50-minute session is $125.00. Your fee/copayment is , and is due in full at each session by cash or check. Telephone conversations of a clinical nature may be charged as regular sessions.
Fees may be renegotiated every six months or whenever your income changes. If you end therapy with an unpaid balance and do not make arrangements to settle the bill, your account may be turned over to a collection agency. Any costs incurred in the collection are your responsibility.Reports and court appearances require professional time for which we charge the full rate of $125.00; court appearances require 4-hour minimum.
INSURANCE:
If applicable, insurance carriers will be billed by the agency. If the full agreed upon fee is not met by your carrier, you are responsible for the balance due.
TREATMENT PLANNING AND EVALUATION:
Since Maria Droste Counseling Center is not a 24-hour crisis-intervention agency, in case of an emergency, you may call Colorado Crisis Support Line at 844-493-8255, or go to your nearest emergency room.
Your therapist can approximate length of treatment and probable results; however, as response differs on an individual basis, guarantees cannot be made as to treatment outcome. As needed, Maria Droste Counseling Center may provide a 2-3 session pre-counseling assessment only for the purpose of determining whether this agency has the appropriate services to meet your needs. If we cannot provide the services you need, your therapist will offer you referral information.
Periodically, client and therapist will assess progress toward treatment goals. It can be mutually beneficial if termination is discussed in advance and a final session is completed.Additionally, we subscribe to a treatment team approach which may include suggesting additional services, such as utilizing a primary care physician, a psychiatrist,or group therapy etc.
OBSERVATIONS/RECORDINGS OF SESSIONS
I understand Maria Droste Counseling Center routinely observes therapy sessions conducted by counseling interns for educational purposes, and that cases are discussed in a confidential manner for training purposes. These observations may occur as audio-visual, solely audio, or observation in the room. If an observation or recording is occurring, my therapist will inform me of this fact.
I understand the recordings will be the property of Maria Droste Counseling Center and will not be part of my record. Recordings will be kept secured and destroyed atthe end of treatment. I also understand if I object to being observed, it will in no way jeopardize my relationship with Maria Droste Counseling Center.
Iagree to session observation. ______Client initials Iagree to session recording.______Client initials
RESEARCH/EVALUATION
I understand Maria Droste Counseling Center may periodically use information from my treatment for program evaluation/research. I also understand if such information is used, my name as well as any identifying information will be removed and not included in evaluation/research. Further, I understand if I decide I do not want my treatment information used for these purposes and/or I don’t want any research-related follow-up contact; my decision will not affect my treatment in any way.
I hereby grant permission for anonymous use of my treatment information, and/or follow-up contact. _____ Client initials
EMERGENCY INFORMATION
In the case of impaired access to the counseling center due to a natural or physical disaster, updates regarding alternative facilities or services will be provided on an immediate and ongoing basis at the main phone number of 303-756-9052and the web site at
I have read the preceding information, and I understand my rights as a client or as the client’s responsible party. I consent to treatment at Maria Droste Counseling Center.
I have been offered/received a copy of the Notice of Privacy Practices._____ Client initials
______
Adult SignatureDateTeen Signature (ages 15-18) Date
______
Adult #2 SignatureDate Therapist Signature Date
I attest that I am authorized to give permission for my child(ren) to have counseling at Maria Droste Counseling Center.
______
Parent/Guardian Signature (of childrenDate Parent/Guardian Signature (of children Date
age 14 and under) age 14 and under)
______
Therapist Signature Date
1355 So. Colorado Blvd., #C100; DenverColorado80222303-756-9052303-756-0308 (fax)
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