/ Informed Consent and
Mandatory Disclosure Form

Tessel Stevenson, MA, LPC

8471 Turnpike Dr, Suite 110

Westminster, CO 80031

(720) 243-9390

tstevensontherapy @gmail.com

TesselStevensonTherapy.com

Your Therapist’s Training

Tessel Stevenson has a Master of Arts Degree in Counseling Psychology from the University of Minnesota and a Bachelor of Arts Degree in Psychology from Colorado College. She is a Licensed Professional Counselor in the State of Colorado (license # 5255) and has worked and trained in numerous clinical settings. A Licensed Profesisonal Counselor must hold a masters degree in their profession and have two years of post-masters supervision. The practice of Licensed Professional Counselors is regulated by the Department of Regulatory Agencies. The State Board of Licensed Professional Counselor Examiners can be reached at 1560 Broadway, Suite 1350, Denver, CO 80202; phone: (303) 894-7800; email:

Professional Fees

Your fee for a 60-minute session is $100. This fee should be paid on the day of your session unless other billing arrangements have been made. There is no charge for appointments cancelled 24 hours in advanced of the scheduled session. Appointments cancelled less than 24 hours ahead of time are charged full fee, excepting cases of emergency.

Your Rights

  • You are entitled to receive information about the methods of therapy, the techniques used, the duration of therapy, if known, and the fee structure.
  • You may seek a second opinion from another therapist or may 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.
  • Your clinical records will be kept for seven years after therapy has terminated and then will be destroyed.
  • The therapist will close a client’s file, terminating therapy, after 6 months if there has been no contact from the client. Should a client’s file be closed, it is possible to resume the therapy process should a client wish to do so.

Limits of Confidentiality

The information provided by the client during therapy sessions is legally confidential, except as provided in section 12-43-218 and except for certain legal exceptions.

  1. A client or the heirs, executors, or administrators of a client file suit or a complaintagainst a licensee, registrant, or certificate holder on any cause of action arising out of orconnected with the care or treatment of the client by the therapist.
  2. Your therapist was in consultation with a physician,registered professional nurse, licensee, registrant, or certificate holder against whom a suit orcomplaint was filed based on the case out of which said suit or complaint arises;
  3. A review of services of a therapist is conducted by anyof the following:
  4. A board or a person or group authorized by the board to make an investigation on its behalf
  5. A professional review committee established pursuant to section 12-43-203 (11) ifsaid person has signed a release authorizing such review;
  6. A client, regardless of age:
  7. Makes an articulable and significant threat against a school or the occupants of aschool; or exhibits behaviors that, in the reasonable judgment of the licensee, registrant, orcertificate holder, create an articulable and significant threat to the health or safety of students,teachers, administrators, or other school personnel.
  8. Threatens grave bodily harm or death to self or to another person.
  9. There is reason to suspect that a child or elderly person is being abused or has been abused, either by neglect, assault, or sexual molestation.
  10. If a court of law issues a subpoena to provide specific information requested in the subpoena.
  11. If a client request that information be released to another party, and in this case, the client must sign release of information documents.

If such a situation occurs in your treatment, Tessel Stevenson will make every effort to fully discuss it with you before taking any action.

Tessel Stevenson may occasionally find it helpful to consult other professionals about a case. During consultation, she always maintains confidentiality regarding a client’s identity. Please note that cellular phone and email communications are vulnerable to breeches of confidentiality due to their modes of transmission.

You (the undersigned) give permission to receive therapy services. You are aware that therapy is not based on an exact science, that it requires your active participation, and that the type of treatment received will depend primarily on the nature of your concerns and needs. You understand that you cannot be given any guarantees about the results of treatment. You also understand that you have the right to seek a second opinion from another therapist and to stop this treatment at any time. You are aware that during therapy you may discuss unpleasant aspects of your life and thus may experience periods of sadness, anger, guilt, anxiety, loneliness, and frustration. This consent and these same rights apply to each member of the family that may be seen in a therapy session.

Agreement

I have read the preceding information and I understand my rights as a client or as the client’s responsible party.

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Client Signature (parent or legal guardian)Date

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Witness SignatureDate

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