Disclosure Statement Document Page _____ of 4
Ashley Davis, MA, LPC
Psychotherapist
777 29th Street, Suite 401
Boulder, Colorado 80303
(303) 919-4149
Disclosure Form/Consent to Treatment
Welcome. I want to help you make informed decisions about your treatment. You have certain rights as a patient of psychotherapy and as a consumer of my services as stated in the Colorado Revised Statute (C.R.S. 12-43-214).
Therefore, I will explain the information you are entitled to know such as my view of the therapeutic process, and my expectations for the cooperative working agreement. Please feel free to ask questions about any of the following information at any point during our work together.
Clients Rights, Policies and Fees
Education: I obtained a Master of Arts degree in Transpersonal Counseling Psychology from Naropa University in Boulder, Colorado. I received a Bachelor of Arts degree in Psychology with a minor in Women’s Studies at Hamilton College in New York. In May 2005, after a 2-year training, I received a graduation certificate from The Gestalt Institute of the Rockies in Golden, Colorado. In addition, I trained in trauma resolution and EMDR I & II and became a EMDRIA Certified Therapist in EMDR. I also trained in Experiential Play Therapy and was a Love & Logic Trainer in Northglenn, Colorado. I recently complete an advanced EMDR training and I am currently enrolled in a two-year Advanced Gestalt Therapy training. Additionally, I am currently working on my PhD in Clinical Psychology.
Training: My clinical experience includes working with children, adolescents, adults, couples, families and groups in a variety of therapeutic settings. Currently, I have a private practice in Boulder and Denver and I am adjunct faculty at Naropa University in the MA Contemplative Counseling Psychology Department. I worked in the Adams County School District working with children, adolescents and their families providing direct mental health clinical assessment and treatment to adolescents and their families in a public school setting. I have also been a chaplain at the Boulder Community Hospital. I volunteered as a mentor for the Interpersonal Violence Prevention Peer Education Program, a collaboration between MESA (Moving to End Sexual Assault) and Boulder County Safehouse to provide support and mentorship to high school peer educators to teach high school and middle school students on the issues of dating abuse, sexual assault, and sexual harassment. In the past, I have worked as a youth development counselor in a long-term residential program for adolescent girls in New York City, and counseled adolescent boys connected to the judicial system in a wilderness therapy program in North Carolina. I have also worked on a rape crisis hotline and worked with children and adults living with HIV/AIDS.
The Therapeutic Process: Counseling has both benefits and risks. Benefits for people who undertake counseling often include a reduction of feelings of distress, more satisfying relationships, and resolution of specific problems. Growth nearly always brings change, and sometimes change (even positive change) causes stress. Potential risks of counseling involve recalling unpleasant aspects of your personal history that may bring up distressing thoughts and feelings. Because of the complexity of human behavior, there are no guarantees that you will feel better or that your problem(s) will be resolved. No one can guarantee the outcome of therapy, and often how well therapy works depends on the fit between client, therapist and therapeutic method. If you have any concerns about your progress or the results of your counseling experience, please talk to me at any time during our work together.
General Structure of Sessions: I do short or long term psychotherapy in weekly or biweekly sessions of a fifty minute period. Length or frequency of sessions can be increased or decreased to reflect the therapy needs of the client. If the client arrives late for a session, he/she is still responsible for the total fee for a complete session.
Scheduling and Cancellations: Since I have reserved our appointment time for you, it is my policy to charge for cancellations received with less than 24 hours notice. See Fee Agreement for more information.
Standard Fee for Services: My fee is $130 for a fifty-minute individual session, unless other terms have been negotiated. There is no fee for brief phone calls. Calls lasting longer than 10 minutes will be charged pro-rated. I do not accept insurance reimbursement. However, a receipt will be given to you and you can obtain reimbursement from your insurance according to your plan. Full payment is due at the end of each session and payment must be made by cash, check or credit card. Returned checks and balances older than 30 days will be subject to an additional $25.00 service charge.
My Availability and Answering Service: I maintain a 24-hour voice messaging service. Every effort will be made to return calls within a 24-hour period, with the exception of weekends and holidays. Please be aware that I use a cell phone for my business, and although it is password protected and confidential, please know that all electronic devices can be susceptible to surveillance.
Emergencies: While every effort is made to respond to you in times of emergencies, I do not carry a pager and do not check messages between 6:00 p.m. and 10:00 a.m. or on holidays. If you have an urgent need, there are community resources that can assist you: the Boulder County Emergency Psychiatric Services at 303-447-1665 or emergency services reached by dialing 911 on your telephone. When I am out of town, I will arrange for a colleague to cover for me in the event of emergencies.
Confidentiality: The information provided by and to a client during therapy sessions is legally confidential and will not be released without the client’s signed consent as stated in the Colorado statutes (C.R.S. 12-43-218). Matters regarding your psychotherapy will be kept confidential except in the following circumstances:
· You sign a release of information giving permission to release information to a specific individual or agency
· If I feel there is a threat to you harming yourself and/or other(s)
· If I suspect child abuse/neglect or dependent adult abuse/neglect
· If legal matters are involved and the therapist and/or records are subpoenaed in Court proceedings including but not limited to child custody, criminal and delinquency cases.
· If there are collection proceedings
· If there is a court order for counseling
· If you become unable to take care of yourself and additional help is required
· If there is a Grievance Board inquiry
· In some cases if you are under the age of 18
· 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 [If you are HIPAA covered add: “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.
New law additionally clarifies that mandatory reporters (as defined in C.R.S. 19-3-304) must make a report regarding an adult’s disclosure of childhood abuse under the following conditions:
· If the mandatory reporter has reasonable cause to know or suspect that the perpetrator of the suspected abuse or neglect has subjected any other child currently under eighteen years of age to abuse or neglect or to circumstances or conditions that would likely result in abuse or neglect; or
· If the alleged perpetrator is currently in a position of trust, as defined in section 18-3-401 (3.5), C.R.S., with regard to any child currently under eighteen years of age.
I am bound by confidentiality in the client-therapist relationship. That means I may not talk to anyone about our work together, including family members, unless I have your written permission, or you are under the age of 18 years. There are exceptions to this mandated law as noted above. If you have seen another therapist or psychiatrist and that information would be helpful to your work with me, you must first agree to sign a written release before I may speak with this professional.
Rights as a Client: In Colorado, the practice of psychotherapy by both licensed and unlicensed persons in the field of psychotherapy is regulated by the state. Any questions, concerns or complaints regarding the practice of mental health professions may be directed to: Department of Regulatory Agencies, State Grievance Board, 1560 Broadway, Suite #1350, Denver, CO, 80202, (303) 894-7766.
· As to the regulatory requirements applicable to mental health professionals: a Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor 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 must hold a masters degree 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 Certified Addiction Counselor I (CAC I) must be a high school graduate, and complete required training hours and 1000 hours of supervised experience. A CAC II must complete additional required training hours and 2,000 hours of supervised experience. A CAC III must have a bachelor’s degree in behavioral health, and complete additional required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical masters degree and meet the CAC III requirements. A Registered Psychotherapist is registered with the State Board of Registered Psychotherapists, is not licensed or certified, and no degree, training or experience is required.
· You are entitled to receive information about methods of therapy, techniques used, duration of therapy (if known), and fee structure. Please ask if you would like to receive this information. You are also to be informed of the therapist’s degrees, credentials and licenses.
· You may seek a second opinion from another therapist or terminate therapy at any time.
· 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.
· Information provided by you during therapy is confidential except in certain circumstances of which you should be informed.
· If I believe your psychotherapeutic issues are above my level of competence, or outside my scope of practice, I am legally required to refer, terminate, or consult.
Records: Your records will be stored safely with attention to your privacy. They can only be released with your permission and direction. I may sometimes summarize the content related to the request rather than release the entire record. You will not be given a photocopy of your record, but you will be granted reasonable access. If you choose to read your record, it is my policy to be present in order to respond to any questions or confusion you many have about the recordings.
Termination: Termination will usually be agreed upon mutually, but you are free to terminate at any time. However, in a few special instances I may decide to stop working with you even though you wish to continue. These include a failure to meet the terms of our fee agreement, a need for special services outside the area of my competency, or prolonged failure to make progress in our work together. Should this occur, the reason for termination will be discussed with you, and you will be helped to make different plans for yourself, including a referral to a more appropriate resource. If it has been 6 months since our last session, you will be considered no longer on my caseload. You are able to reopen your case at any time.
Permission for Professional Use of Therapy Material: I give permission to Ashley Davis to use incidents from my therapy work with her as examples in her professional work (papers, articles, books, lectures, training groups and workshops) on psychotherapy. I understand that while the examples will be vivid enough to convey a sense of what happened, the details will be altered if this is necessary to protect my identity. My name, of course will not be used in this material.
If I Need To Contact Someone About You: If there is an emergency during our work together, or I become concerned about your personal safety, I am required by law and by the rules of my profession to contact someone close to you - perhaps a relative, spouse or close friend. I am also required to contact this person or the authorities if I become concerned about you harming someone else. Please write down the name and information of your chosen contact person in the blanks provided in case of an emergency only.
Name:______
Address:______
Phone:______Relationship to you:______
Email (to email paperwork/receipt for sessions):______