Before we begin our sessions together, please complete the enclosed forms:

Transcription

1 Welcome! I am honored that you would consider allowing me to walk with you on your journey. You re taking a courageous step. You deserve to be heard, healthy, and whole. Before we begin our sessions together, please complete the enclosed forms: Disclosure Statement Communication Form Please bring both forms fully completed to our first session together. Or you can it to me at tara@hedmancounseling.com prior to our first session. If you have any questions before our first session, please do not hesitate to contact me. I look forward to beginning with you soon. Sincerely, 10 Boulder Crescent Suite 204D Colorado Springs, CO T: W:

2 Tara Hedman Disclosure Statement This statement is intended to provide you, the client, with important information regarding the practices, policies, and procedures of Hedman Counseling and to clarify the terms of the professional therapeutic relationship between client and registered psychotherapist. Any questions about the material contained in the statement or concerns with the contents of this agreement should be discussed prior to signing. Education: Regis University: B.S. Applied Psychology, 2010 Walden University: M.S. Mental Health Counseling (projected graduation 2014) Regulations: The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The Board of Registered Psychotherapist Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) As to the regulatory requirements applicable to mental health professionals: 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. 2 of 6 Client Initials

3 Certified Addiction Counselor I (CAC I) must be a high school graduate, complete required training hours and 1,000 hours of supervised experience. Certified Addiction Counselor II (CAC II) must complete additional required training hours and 2,000 hours of supervised experience. Certified Addiction Counselor III (CAC III) must have a bachelor s degree in behavioral health, complete additional required training hours and 2,000 hours of supervised experience. Licensed Addiction Counselor must have a clinical master s degree and meet the CAC III requirements. Licensed Social Worker must hold a master s degree in social work. 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. Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a master s 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. Confidentiality: 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 of the Colorado Revised Statutes, as well as other exceptions in Colorado and Federal law. For example, mental health professionals are required to report suspected child abuse to authorities. If a legal exception arises during therapy, if feasible, you will be informed accordingly. The Mental Health Practice Act (CRS 3 of 6 Client Initials

4 , et seq.) is available at: Therapeutic Relationship: 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. Treatment: You are entitled to receive information from your therapist about the methods of therapy, the techniques used, the duration of your therapy (if known), and the fee structure. You can seek a second opinion from another therapist or terminate therapy at any time. Emergency Information: If, for any reason, you are unable to contact us by telephone and are having a mental health emergency, please call the 24-hour Pikes Peak Mental Health crisis line at or the crisis hotline in your area. Also you may call 911 or go to the nearest hospital emergency room. Payment: Appointments will be billed the business day prior to the appointment. Any changes to an appointment require a full 48 business hours notice. There are no refunds for appointments that are not kept or rescheduled more than 48 hours business hours in advance. You are responsible for scheduling a new appointment if there has been a missed or cancelled session. Initial assessment sessions are billed at the time of booking and are non-refundable. 4 of 6 Client Initials

5 I have read the preceding information, it has also been provided verbally, and I understand my rights as a client or as the client s responsible party. By signing this Disclosure Statement, I also agree to permit consultation and I provide release for my therapist to seek consultation with other psychotherapists or professionals as the need arises. Client s name - Please Print Date Client s Signature (Parent or Guardian of Minor) Date If signed by parent or guardian, please state relationship to client: Communication Statement General Information: Date: Full Name: Social Security Number: Age: Date of Birth: / / 5 of 6 Client Initials

6 Street Address: Suite/Apartment Number: City: State: Zip Code: May I Send Mail Here: Home Phone: ( ) May I Leave a Message Here: Cell Phone: ( ) May I Leave a Message Here: Work Phone: ( ) May I Leave a Message Here: May I Send Here: Yes No Referral Information: How did you hear about Hedman Counseling? May I thank them for the referral? Emergency Contact Information: Name: Relationship: Home Phone: ( ) Mobile Phone: ( ) 6 of 6 Client Initials

7 By signing the Communication Statement, I agree to permit Hedman Counseling to contact me by methods indicated by checking Yes or No above. I also agree to permit Hedman Counseling to contact my emergency contact in the case of an emergency. Client s name - Please Print Date Client s Signature (Parent or Guardian of Minor) Date If signed by parent or guardian, please state relationship to client: 7 of 6 Client Initials