Jeff Caster, Ph
Kwai Kendall-Grove, Ph.D.
Licensed Clinical Psychologist
2305 East Arapahoe Road
SG Plaza Suite 149
Centennial, CO 80122-1538
303-662-9670
DISCLOSURE AND INFORMED CONSENT
Welcome to my practice. This document contains important information about my professional services. Please feel free to ask me questions after reading this form.
EDUCATION AND EXPERIENCE
I, Dr. Kwai Kendall-Grove, have a Doctorate in Clinical Psychology from the University of Washington and a B.A. Cum Laude in Psychology from Amherst College. I completed my Clinical Psychology internship at Stanford University. I have been a licensed psychologist in the state of Colorado since 1999. I hold Colorado License Number #2321. am an independent practitioner, and, as such, am not legally or professionally affiliated with any other mental health professional.
PSYCHOLOGICAL SERVICES
It is my goal to provide you with empathetic, evidence based psychotherapy and assessment. There are many different methods I may use to treat the psychological problems that you present with. I draw from many different psychological treatment models to treat psychiatric disorders including psychodynamic, developmental, cognitive-behavioral therapy, skills based treatment (DBT), family systems, and solution focused approaches. The treatment model that I implement is informed by my training, the psychological issues that you present with, and evidence based treatment, i.e., what works.
Psychotherapy can have benefits and risks. It calls for an active effort on your part, and a desire to make changes within yourself and your environment. Psychotherapy typically involves discussing emotions that may be comfortable to discuss and you may find that, in discussing these emotions that your symptoms may worsen temporarily before you get better. In order for therapy to be most successful, you will have to work on things we discuss in therapy outside of our sessions. I may also give you handouts or homework assignments that will describe techniques that you have learned during the sessions for you to work on outside of therapy.
Our first session or two will involve an evaluation of your psychological needs. At the end of the evaluation, I will offer you some initial impressions and discuss my diagnostic impressions. If you have questions about my procedures, please feel free to discuss them with me. If, at any point, you feel like treatment is not progressing how you would like, please let me know and I will refer you to another mental health professional.
YOUR RIGHTS
As a client seeking mental health services, you have certain rights. These include your right to seek a second opinion from another therapist and your right to terminate this therapy at any time. You are also entitled to receive information regarding the methods of therapy, techniques used, the duration of therapy, if known, and the fee structure.
The Colorado Department of Regulatory Agencies regulates the practice of psychology in Colorado. The agency within the Department that has responsibility for licensed and unlicensed psychotherapists is the Department of Regulatory Agencies. Any questions or concerns regarding your mental health treatment may be directed to:
State Grievance Board
1560 Broadway, Suite 1370
Denver, Colorado 80220
Phone: 303-894-7766
THERAPEUTIC RELATIONSHIP
Your relationship with me is a professional and therapeutic relationship. In order to preserve 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. Gifts, bartering, and trading services are not appropriate and should not be shared between us. Additionally, sexual intimacy is never appropriate in a therapeutic relationship. Any circumstances of sexual intimacy within a therapeutic relationship should be reported to the grievance board listed above.
MEETINGS
During our initial sessions we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If we agree that psychotherapy with me is a good fit for you (and your spouse/family), I will schedule appointments as dictated by the treatment that is indicated given your presenting problem. Decreased psychotherapy sessions will be determined by a discussion of how you feel like you are progressing, and by a decrease in psychological symptoms.
CANCELLATION POLICY
There is no charge for appointments cancelled 48 hours in advance of the scheduled time. Appointments cancelled less than 48 hours ahead of time are charged the full fee. If you need to cancel your appointment with me, please leave me a message at my private practice number, (303) 662-9670 as soon as you know you will not be able to keep your appointment time with me. This will allow me to give your appointment time to another patient or family who would like it.
PROFESSIONAL FEES
My fee for the initial consultation (1 hour) is $175. Subsequent 45-minute sessions are also charged at a rate of $175. Payment is due at the time of service. I accept cash, check, and Visa/Master Card. Please see my Payment Information Form for additional information about payment.
I will provide you with a billing statement on a monthly basis. This statement will have all of the necessary documentation (insurance codes, my Tax ID#, and diagnostic codes) that you may need to seek reimbursement from your insurance company. It is your responsibility to submit this claim to your insurance company directly. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include report writing, writing behavioral plans, emergency sessions, emergency phone calls, telephone conversations lasting longer than 5 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. Payments more than 30 days overdue will incur a $25.00 late fee. Payments more than 60 days overdue will be charged another $25.00 and will be automatically sent to a collections agency. Patients are responsible for all collections agency fees.
Payments that are over 30 days past due will incur a $25.00 late fee charge.
Custody/Divorce Situations:
If you are involved in divorce or custody litigation, my role as a psychologist is NOT to make any recommendations to the court regarding custody or parenting issues. By signing this disclosure statement, you agree to NOT subpoena me to testify or disclose treatment information. Furthermore, you agree NOT to request that I write any reports to the court or to your attorney regarding custody and parenting issues. The court can appoint professionals, who have no prior relationships with family members, to conduct an evaluation or investigation concerning matters such as parenting responsibilities or parenting time.
Cognitive/Psycho-educational and/or Extensive psychological evaluations (i.e., testing)
Cognitive/Psycho-educational and/or extensive psychological evaluations that involve standardized testing are charged at the same rate of $175 per 45 minute/hour. Because of the extensive, and time-consuming nature of such evaluations, I require a $500 retainer at the first appointment. This $500 fee will be credited to the overall cost of the evaluation. A rate of $175 per 45 minute session for test administration, test scoring, consultation with other professionals (school, psychiatrists, medical providers, etc), and necessary phone calls will be billed. You will receive a bill at the end of the cognitive and/or psychological evaluation for the total cost of the evaluation minus the retainer fee. The final bill will detail time spent for the clinical interview, test administration, test scoring, report writing, necessary telephone calls, and feedback sessions. The final written evaluation will be released to you once payment is made in full.
CONTACTING ME
Phone Contact:
I am often not immediately available by telephone. When I am often in my office, I do not answer the phone when I am with a client, and my telephone is answered by voice mail that I check a number of times per day. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. On weekends and holidays, I will return your call on the next day I am back in the office. If you are difficult to reach, please inform me of some times that you are available, and multiple phone numbers that I can reach you at. If you have an urgent need and feel that you cannot wait for me to return your call, you can call 911 or call me on my cell phone. This number is to be used for emergency situations only. That number is (303) 525-9238. When I am out of town for an extended period, I will arrange emergency coverage with a mental health professional whose telephone number will be available from my voice mail.
Email Contact:
I have an email account that you can access through my website at www.drkendallgrove.com. Please note that I only use email as a way to schedule appointments with patients who prefer email. Email is not an acceptable form of communication to cancel appointments with me. If you need to cancel an appointment with me, please leave me a message at my private practice. In addition, I do not use email communication with patients to discuss clinical matters, answer clinical questions, or billing concerns. Finally, email is not an acceptable way to communicate a clinical emergency. If you are having a clinical emergency, please call me at my private practice and then call me cell phone pager.
PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. Clients will be charged an appropriate fee for any professional time spent in responding to information requests.
CONFIDENTIALITY
Right to Privacy
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 and the Health Information Portability and Accountability Act. 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
In general, the law protects the privacy of all communications between a client and a psychologist, and I can only release information about our work to others with your written permission. Furthermore, information disclosed to a licensed psychotherapist is privileged communication and cannot be disclosed in any court of competent jurisdiction in the State of Colorado with the consent of the person to whom the testimony relates. But there are a few exceptions.
There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client's treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I am legally mandated to file a report with the appropriate state agency.
If I believe that a client is threatening serious bodily harm to another, I am again legally required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. I also may occasionally consult with other experts on treatment issues. In the event of such a consultation, your identity or any possibly identifying information will not be revealed. It is important that we clearly outline such information to be sure that everyone understands the extent and degree of confidentiality in such cases. Please ask me any questions you may have around this issue.
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 record, unless I decide that such access is likely to injure the child. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child’s records. It 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. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.
AGREEMENT
I want you to know that it is very important to me that in response to this form, or any time during our work together, I want you to feel free to voice questions or concerns. I look forward to working with you.
Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
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Client Signature Date
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Parent/Guardian Signature Date
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Parent/Guardian Signature Date
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Kwai Kendall-Grove, Ph.D. Date
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