REGULATION OF MENTAL HEALTH PROFESSIONALS IN
COLORADO:
1. Hedman Counseling, PC is located at 4297
Austin Bluffs Parkway, Suite 204; Colorado Springs, CO 80918;
719-235-5325. The mental health professional located
at Hedman Counseling, PC is Rachael
Rosner. Rachael earned a Bachelor of Arts in Communications
from DePaul University in 2013 and earned
a Masters degree in ClinicalMental Health Counseling from
the University of Colorado at Colorado Springs in 2020.
2. Everyone twelve (12) years and older must sign this
disclosure statement. A parent or legal guardian with the
authority to consent to mental health services for a minor
child/ren in their custody must sign this disclosure statement on
behalf of their minor child under the age of twelve (12) years
old. A parent or legal guardian with the authority to
consent to mental health services for a minor child/ren in their
custody must also sign this disclosure statement on behalf of
their minor child over the age of twelve (12) but under the age
of fifteen (15) years old, unless said minor is voluntarily
seeking psychotherapeutic services for themselves without their
parent's or legal guardian's knowledge or consent. In this case,
the minor who is between the age of twelve (12) and fourteen (14)
years old, in addition to this disclosure statement, shall also
sign a Voluntary Consent for Psychotherapeutic Services form.
The mental health professional providing services to a minor
between the age of twelve (12) and fourteen (14) may advise the
minor's parent or legal guardian of services provided with the
consent of the minor or a court in specific circumstances, unless
notifying the parent or legal guardian would be inappropriate or
detrimental to the minor's care and treatment. The mental health
professional may notify the parent or legal guardian, without the
minor's consent, if in their professional opinion the minor is
unable to manage their own care or treatment, or if the minor
expresses any suicidal ideation.
In divorce or custody situations and because of the Colorado
Department of Regulatory Agencies view on parental consent, it
is Hedman Counseling, PC/Rachael Rosner's policy to
seek the consent of both parents/legal guardians, however this
consent does not supersede any court order outlining parental
decision-making and custodial rights. This policy is irrespective
of any court determination and this is the governing policy
unless the child's health, safety, and welfare could be at risk.
If this is the case, you must inform Hedman Counseling,
PC/Rachael Rosner so that appropriate action for the
protection and welfare of the child may be taken. This disclosure
statement contains the policies and procedures
of Hedman Counseling, PC/Rachael Rosner and is
HIPAA compliant. No medical or psychotherapeutic information, or
any other information related to your privacy, will be revealed
without your permission unless mandated by Colorado law and
Federal regulations (42 C.F.R. Part 2 and Title 25, Article 4,
Part 14 and Title 25, Article 1, Part 1, CRS and the Health
Insurance Portability and Accountability Act (HIPAA), 45 C.F.R.
Parts 142, 160, 162 and 164).
3. The Colorado Department of Regulatory Agencies ("DORA"),
Division of Professions and Occupations ("DOPO") has the
general responsibility of regulating the practice
of Licensed Psychologists, Licensed Social Workers, Licensed Professional Counselors, Licensed Marriage
and Family Therapists, Certified and
Licensed Addiction
Counselors, and registered individuals who
practice psychotherapy. The agency within DORA
thatspecifically has responsibility is the Mental Health
Section, 1560 Broadway, Suite #1350, Denver, CO 80202, (303)
894-2291 or (303)
894-7800; DORA_MentalHealthBoard@state.co.us. The State
Board of Registered
Psychotherapists regulates Registered Psychotherapists,
and can be reached at the address listed above. Clients
are encouraged, but not required, to resolve any grievances
through Hedman Counseling, PC/Rachael Rosner's internal
process.
4. You, as a client, may revoke your consent to treatment
or the release or disclosure of confidential
information at any time in writing and given to your
therapist.
5. Levels of Psychotherapy Regulation in Colorado
include Licensing (requires minimum education, experience,
and examination qualifications), Certification (requires minimum
training, experience, and for certain levels, examination
qualifications), and Registered Psychotherapist (does not require
minimum education, experience, or examination
qualifications). All levels of regulation require passing a
jurisprudence take-home examination.
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 masters
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 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. Registered Psychotherapist is a
psychotherapist listed in Colorado'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. Registered psychotherapists are
required to take the jurisprudence exam.
6. I am a Licensed Professional Counselor Candidate, listed
in the Colorado database, and thereby authorized to practice
mental health counseling. I seek ongoing education and
consultation with other mental health professionals.
CLIENT RIGHTS AND IMPORTANT INFORMATION:
As a client you are entitled to receive information from me about
my methods of therapy, the techniques I use, the duration of your
therapy, if I can determine it, and my fee structure. Please ask
if you would like to receive this information.
Fees:
1. My fee structure, services, and fee policy are outlined as
follows:
a. $120.00 per clinical hour.
I also offer a reduced fee structure for those with
significant financial need. If you are unable to pay the standard
hourly fee, please talk to me about alternative payment options.
Hedman Counseling is proud to support the non-profit organization
Love146. For every counseling session you purchase with Hedman
Counseling, a portion of the proceeds are donated to Love146.
b. Administrative or research services required for
adjunct services outside of Hedman Counseling Center will be
charged at $120.00 per hour.
c. It is the policy of my practice to collect all
fees at the time of service, unless you make arrangements for
payment and we both agree to such an arrangement. In addition, I
request that you fill out a "Credit Card Authorization" form to
keep in your file. All accounts that are not paid within thirty
(30) days from the date of service shall be considered past due.
If your account is past due, please be advised that I may be
obligated to turn past due accounts over to a collection agency
or seek collection with a civil court action. By signing below,
you agree that I may seek payment for your unpaid bill(s)
with the assistance of a collections agency. Should this
occur, I will provide the collection agency or Court with your
Name, Address, Phone Number, and any other directory information,
including dates of service or any other information requested by
the collection agency or Court deemed necessary to collect the
past due account. I will not disclose more information than
necessary to collect the past due account. I will notify you of
my intention to turn your account over to a collection agency or
the Court by sending such notice to your last known address.
d. Therapy fees and treatment are based on
a 45-55 minute clinical hour instead of a 60
minute clock hour so that I may review my notes and assessments
on your behalf.
e. I am not a Medicaid
provider. If you have Medicaid coverage that includes mental
health services, I am not able to offer
mental health services to you. We are not paneled directly
with any insurance companies.
f. Legal Services incurred on your behalf are
charged at a higher rate including but not limited to: attorney
fees I may incur in preparing for or complying with the requested
legal services, testimony related matters like case research,
report writing, travel, depositions, actual testimony, cross
examination time, and courtroom waiting time. The higher fee is
$500.00 per hour.
Restrictions on Uses:
2. You are entitled to request restrictions on certain uses and
disclosures of protected health information as provided by 45 CFR
164.522(a), however Hedman Counseling, PC/Rachael
Rosner is not required to agree to a restriction request.
Please review Hedman Counseling, PC/Rachael Rosner's
Notice of Privacy Policies for more information.
Second Opinion and Termination:
3. You are entitled to seek a second opinion from another
therapist or terminate therapy at any time.
Sexual Intimacy:
4. In a professional relationship (such as psychotherapy), sexual
intimacy between a psychotherapist and a client
is never appropriate. If sexual intimacy
occurs it should be reported to DORA at (303) 894-2291, Mental
Health Section, 1560 Broadway, Suite 1350, Denver, Colorado
80202; State Board of Registered Psychotherapists.
Confidentiality:
5. Generally speaking, the information provided by and to a
client during therapy sessions is legally confidential if the
psychotherapist is a Licensed Psychologist, Licensed Social
Worker, Licensed Professional Counselor, Licensed Marriage and
Family Therapist, Certified and Licensed
Addiction Counselor, or a Registered Psychotherapist.
If the information is legally confidential, the psychotherapist
cannot be forced to disclose the information without the client's
consent or in any court of competent jurisdiction in
the State of Colorado without the consent of the person to whom
the testimony sought relates.
6. There are exceptions to this general rule of legal
confidentiality. These exceptions are listed in the Colorado
statutes, C.R.S. 12-43-218. You should be aware that
provisions concerning disclosure of confidential
communications does not apply to any delinquency or
criminal proceedings, except as provided in C.R.S 13-90-107.
There are additional exceptions that I will identify to you as
the situations arise during treatment or in our professional
relationship. For example, I am required to report child abuse or
neglect situations; I am required to report the abuse or
exploitation of an at-risk adult or elder or the
imminent risk of abuse or exploitation; if I determine that you
are a danger to yourself or others, including those identifiable
by their association with a specific location or entity, I am
required to disclose such information to the appropriate
authorities or to warn the party, location, or entity you have
threatened; if you become gravely disabled, I am required to
report this to the appropriate authorities. I may also disclose
confidential information in the course of supervision or
consultation in accordance with my policies and procedures, in
the investigation of a complaint or civil suit filed against me,
or if I am ordered by a court of competent jurisdiction to
disclose such information. You should also be aware that if you
should communicate any information involving a threat to yourself
or to others, I may be required to take immediate action to
protect you or others from harm. In addition, there may be other
exceptions to confidentiality as provided by HIPAA regulations
and other Federal and/or Colorado laws and regulations that may
apply.
Additionally, although confidentiality extends to communications
by text, email, telephone, and/or other electronic means, I
cannot guarantee that those communications will be kept
confidential and/or that a third-party may not access
our communications. Even though I may utilize state of the art
encryption methods, firewalls, and back-up systems to help secure
our communication, there is a risk that our electronic or
telephone communications may be compromised, unsecured, and/or
accessed by a third-party. Please review and fill
out Hedman Counseling, PC/Rachael Rosner's Consent for
Communication of Protected Health Information by Unsecure
Transmissions.
"No Secrets" Policy:
7. When treating a couple or a family, the couple or family
is considered to be the client. At times, it may be necessary to
have a private session with an individual member of that couple
or family. There may also be times when an individual member of
the couple or family chooses to share information in a
different manner that does not include other members of the
couple or family (i.e on a telephone call, via email, or via
private conversation). In general, what is said in these
individual conversations is considered confidential and will not
be disclosed to any third party unless your therapist is required
to do so by law. However, in the event that you disclose
information that is directly related to the treatment of the
couple or family it may be necessary to share that information
with the other members of the couple or the family in order to
facilitate the therapeutic process. Your therapist will
use theirbest judgment as to whether, when, and to what
extent such disclosures will be made. If appropriate, your
therapist will first give the individual the opportunity to make
the disclosure themselves. This "no secrets" policy is
intended to allow your therapist to continue to treat the couple
or family by preventing, to the extent possible, a conflict of
interest to arise where an individual's interests may not be
consistent with the interests of the couple or the family being
treated. If you feel it necessary to talk about matters that you
do not wish to have disclosed, you should consult with a separate
therapist who can treat you individually.
When two or more individuals are included in the therapeutic
setting and the system/relationship is considered the 'client',
each party is required to sign a separate statement of the
release of information for the request to be honored.
"No Secrets" in Custody Circumstances Policy:
8. When treating a Client who is a Minor under the age of
fifteen (15) and where there exists a custody arrangement between
the parents or legal guardians (such as a divorce or separation),
it is my policy to communicate with both parents/guardians via
email (i.e. all communication will "cc" both parties). This
policy is necessary to maintain transparency and professionalism,
and to ensure the well-being of the therapeutic relationship with
the Minor Client. This policy does not supersede any court order
outlining decision-making or custodial rights but is or may be
required by DORA. Further, I reserve the right, in my sole
discretion, to engage in any individual email communication or
face-to-face interaction in the lobby/waiting area. In the event
that such an interaction occurs, I will notify the other party of
said interaction and summarize the contents of the conversation,
unless prohibited by professional rules or regulations regarding
the protection of the health, safety, and welfare of the
child/ren.
This policy will also be extended to clients who are over the age
of twelve (12) but under the age of fifteen (15) when and if
their parents or legal guardians are notified of their receiving
psychotherapeutic services.
Extraordinary Events:
9. In the case that I become disabled, die,
or am away on an extended leave of absence (hereinafter
"extraordinary event,") the following Mental Health Professional
Designee will have access to my client files. If I
am unable to contact you prior to the extraordinary event
occurring, the Mental Health Professional Designee will contact
you. Please let me know if you are not comfortable with
the below listed Mental Health Professional Designee
and wewill discuss possible alternatives at this time.
Tara Hedman, Unlicensed Psychotherapist
4297 Austin Bluffs Parkway Suite 204
Colorado Springs, CO 80918
Telephone: 719-235-5325
The purpose of the Mental Health Professional Designee is to
continue your care and treatment with the least amount of
disruption as possible. You are not required to
use the Mental Health Professional Designee for therapy
services, but the Mental Health Professional Designee
can offer you referrals and transfer your client record, if
requested.
Maintenance of Client Records:
10. As a client, you may request a copy of your Client Record at
any time. In accordance with the Rules and Regulations of the
State Board of Licensed Professional
Counselors, Hedman Counseling, PC/Rachael
Rosner will maintain your client record (consisting of
disclosure statement, contact information, reasons for therapy,
notes, etc.) for a period of seven (7) years after the
termination of therapy or the date of our last contact, whichever
is later. Hedman Counseling, PC/Rachael
Rosner cannot guarantee a copy of your Client Record will
exist after this seven-year period.
Electronic Records:
11. Hedman Counseling, PC/Rachael Rosner may keep
and store client information electronically
on HedmanCounseling, PC/Rachael Rosner's laptop or desktop
computers, and/or some mobile devices. In order to maintain
security and protect this
information, Hedman Counseling, PC/Rachael
Rosner may employ the use of firewalls, antivirus
software, changing passwords regularly, and
encryption methods to protect computers and/or mobile
devices from unauthorized
access. Hedman Counseling, PC/Rachael
Rosner may also remotely wipe out data on mobile
devices if the mobile device is lost, stolen, or
damaged. Hedman Counseling, PC/Rachael Rosner may
use electronic backup systems such as external hard
drives, thumb drives, or similar methods. If such backup methods
are used, reasonable precautions will be taken to ensure the
security of this equipment and they will be locked up for
storage. Hedman Counseling, PC/Rachael Rosner uses
a cloud-based service for storing or backing up
information.The cloud-based backup
system Hedman Counseling, PC/Rachael Rosner uses
is Counsol.com and the email service
provider Hedman Counseling, PC/Rachael Rosner uses
is Counsol.com. Hedman Counseling, PC/Rachael
Rosnermay maintain the security of the electronically
stored information through encryption and passwords.
In addition, inorder to maintain security of the
electronically stored information Hedman Counseling,
PC/Rachael Rosner has employed the following security
measures:
- Entered into a HIPAA Business Associates Agreement with
the cloud-based Hedman Counseling, PC/Rachael
Rosner and email service provider. Because of this
Agreement, the cloud-basedHedman Counseling, PC/Rachael
Rosner and email service provider are obligated by
federal law to protect the electronically stored
information from unauthorized use or disclosure.
- The computers that store the electronically stored
information are kept in secure data centers, where various
security measures are used to maintain the protection of the
computers from physical access by unauthorized persons.
- The cloud-based Hedman Counseling,
PC/Rachael Rosner and email service provider employ
various security measures to maintain the protection of these
backups from unauthorized use or disclosure.
It may be necessary for other individuals to have
access to the electronically stored information, such
as the cloud-based Hedman Counseling,
PC/Rachael Rosner or email service provider's workforce
members, in order to maintain the system
itself. Federal
law protecting the electronically stored
information extends to these workforce members. If
you have any questions about the security
measures Hedman Counseling, PC/Rachael
Rosner employs, please ask.
12. I acknowledge that communications with
my therapist (e.g. emails, chats, or video sessions)
via HedmanCounseling, PC/Rachael Rosner's client portal are
encrypted and that emails sent from or to personal email accounts
are not secure. I acknowledge and agree that all
communication of a clinical nature should be sent through the
Hedman Counseling Center client portal. A reasonable attempt will
be made by my therapist to read and respond to the
emails received via that site within business 72 hours. I
understand that my therapist will not respond to personal
and clinical concerns via regular email or texting. Email
should not be used in the event of crisis or
emergency. As a rule, personal and clinical
communications (i.e. communication for purposes other than
scheduling) should be reserved for scheduled session times
(in-person sessions, video sessions, email sessions, or phone
sessions) except in cases of emergency. I further
acknowledge that if either I or my therapist uses a
cell phone that the conversation may not be secure and
therefore not confidential. Although my therapist has
taken substantial steps to ensure the confidentiality and privacy
of therapy provided online, Hedman Counseling,
PC/Rachael Rosner cannot guarantee the security of any
internet or cell phone transmissions or communications.
I agree to take full responsibility for the security of any
communication or treatment documentation on my own computer
and in my physical location. If mytherapist believes I am a
danger to, or may become a danger to, yourself or anyone
else, my therapist may inform others or insist that
I be evaluated, in person, by another health care
professional.
Availability and Response Policy:
13. Our normal business hours are
from Monday to Friday, 9:00am - 8:00pm,
and Saturday 9:00am - 4:00pm. However, as a therapist, the
majority of our business hours are devoted to seeing
clients in therapy, which means I am not always available for
immediate contact via phone, text, or email. This is
especially true for emergencies, as I am not equipped to respond
immediately.
The best way to contact me is via (phone/email). Every effort
will be made to respond to you in a clear and timely manner.
Voicemails and texts sent to 719-235-5325 will be returned
within 48 business hours, excluding Saturdays, Sundays,
and holidays. Emails sent
to movingforward@hedmancounseling.com will be
returned within 48 businesshours, excluding Saturdays,
Sundays, and holidays. It is my policy to return all phone calls,
texts, and emails during my normal business hours (referenced
above). I also reserve the right, in my sole discretion, to
return communication outside of these hours; but any
communication which I initiate outside of these normal business
hours is in no way a guarantee or a promise of availability
outside of my normal business hours.
AS A CLIENT:
You as a Client agree and understand the following:
1. I understand that Hedman Counseling, PC/Rachael
Rosner may contact me to provide appointment reminders or
information about treatment alternatives or other health-related
benefits and services that may be of interest to me in
accordance with Hedman Counseling, PC/Rachael Rosner's
Consent for Communication of Protected Health Information by
Unsecure Transmissions.
2. I understand that if I initiate communication via electronic
means that I have not specifically consented to
in Hedman Counseling, PC/Rachael Rosner's Consent for
Communication of Protected Health Information by Unsecure
Transmissions, I will need to amend the consent form so that my
therapist may communicate with me via this method.
3. I understand that there may be times when my therapist may
need to consult with a colleague or another
professional, such as an attorney or supervisor, about
issues raised by me in therapy. My confidentiality is still
protected during consultation by my therapist and the
professional consulted. Only the minimum amount of
information necessary to consult will be disclosed. Signing
this disclosure statement gives my therapist permission to
consult as needed to provide professional services to me as a
client. I understand that I will need to sign a
separate Authorization for Release of Information for
any discussion or disclosure of my protected health information
to another professional besides a colleague, supervisor
or attorney retained by my therapist.
4. I understand that,
in general, Hedman Counseling, PC/Rachael
Rosner does not provide Teletherapy, such as therapy
over telephone or video chat. I understand that
communications via email and text should be limited to
administrative purposes and not used as an avenue for therapy. I
understand that should I want Teletherapy, I will discuss my
request with my therapist. I understand that it is in my
therapist's sole discretion whether to accommodate my
request for Teletherapy. Should my therapist and I determine
that Teletherapy is an appropriate option for my treatment, I
understand that no portion of sessions shall be recorded by
client or therapist without prior written consent and that I will
be required to sign a separate teletherapy disclosure statement.
If client or therapist is unable to attend in-office appointment
due to inclement weather or other unforeseen circumstances, when
feasible session may take place by phone or secure video chat at
the previously agreed upon time. Payment cancellation policies
remain in effect. Please discuss this option with your
therapist in advance if you wish to utilize this option.
5. I understand that my therapist, does not accept
personal Facebook, LinkedIn, Twitter, Instagram, and/or
other friend/connection/follow requests via any Social
Media. Any such request will be denied in order to
maintain professional boundaries. I understand
that Hedman Counseling, PC/Rachael Rosner has, or
may have, a business social media account page. I understand
that there is no requirement that I "like" or
"follow" this page. I understand that should I "like"
or choose to "follow" Hedman Counseling, PC/Rachael
Rosner's business social media page that others will
see my name associated with "liking" or
"following" that page. I understand that this applies
to any comments that I post on Hedman Counseling,
PC/Rachael Rosner's page/wall as well. I understand that any
comments I post regarding therapeutic work between my therapist
and I will be deleted as soon as possible. I agree that I
will refrain from discussing, commenting, and/or asking
therapeutic questions via any social media platform. I agree that
if I have a therapeutic comment and/or question that I will
contact my therapist through the mode I consented to
and not through social media.
6. I understand that Hedman Counseling, PC/Rachael
Rosner uses testimonials in its marketing efforts. I
understand that I will never be asked to provide a testimonial
and I am not required or expected to provide one. If I wish
to provide a testimonial regarding my experience
with Hedman Counseling, PC/Rachael Rosner, I may put
the information in writing and provide it to my therapist, along
with my signature and the following statement: "It is my
intent to provide Hedman Counseling, PC/Rachael
Rosner with a testimonial to be used in its marketing
efforts. I offer this of my own volition and have not been
solicited to provide this testimonial. I understand that it may
be possible for others to identify me based on the information I
provide." No client names will be disclosed in
testimonials.
7. I understand that if I have any questions regarding social
media, review websites, or search engines in connection to
my therapeutic relationship, I will immediately contact my
therapist and address those questions.
8. I understand my therapist
provides non-emergency therapeutic
services by scheduled
appointment only. If, for any reason, I
am unable to contact my therapist by the telephone
number provided to me, 719-235-5325, and I am
having a true emergency, I will
call 911, check myself into the nearest hospital
emergency room, call Pikes Peak Mental Health Crisis
Line at 719-635-7000, Colorado's Crisis Hotline (844)
493-8255 or the National Suicide Prevention Lifeline at
1-800-273-TALK(8255). Hedman Counseling, PC/Rachael
Rosner does not provide after-hours service without an
appointment. If I must seek after-hours treatment from
any counseling agency or center, I understand that I will
be solely responsible for any fees due. I
understand that if I leave a voicemail for my therapist on the
phone number provided, my therapist will return my call by the
end of the next business day, excluding holidays and
weekends.
9. If my therapist believes my therapeutic
issues are above their level of competence, or outside
of their scope of practice, my
therapist is legally required to refer,
terminate, or consult.
10. I understand Hedman Counseling, PC/Rachael
Rosner is not paneled with any insurance companies and
payment is due at time of service. I
understand Hedman Counseling does not file directly for
out of network benefits on behalf of the client. I
understand that I am legally responsible for payment for my
therapy services. If for any reason, my
insurance company, HMO, third-party payer, etc. does
not compensate my therapist, I understand that I
remain solely responsible for payment. I also
understand that signing this form gives permission to my
therapist to communicate with my insurance, HMO, third-party
payer, collections agency or anyone connected to my therapy
funding source regarding payment. I understand that my
insurance may request information from my therapist about the
therapy services I received which may include but is not limited
to: a diagnosis or service code, description of services or
symptoms, treatment plans/summary, and in some cases
my therapist's entire client file. I understand that
once my insurance receives the information I or my
therapist has no control of the security measures the
insurance company takes or whether the
insurance company shares the required information. I
understand that I may request from my therapist a copy of any
report Hedman Counseling, PC/Rachael
Rosner submits to my insurance company on my
behalf. Failure to pay will be a cause for termination
of therapy services.
11. I understand that this form is compliant with HIPAA
regulations and no medical or therapeutic information or
other information related to my privacy, will be released without
permission unless mandated by Colorado law as described in this
form and the Notice of Privacy Policies and
Practices. By signing this form, I agree and acknowledge I
have received a copy of the Notice or declined a copy at this
time. I understand that I may request a copy of the Notice at any
time.
12. I understand that if I have any questions about my
therapist's methods, techniques, or duration of therapy, fee
structure, or would like additional information, I may ask at any
time during the therapy process. By signing this disclosure
statement I also give permission for the inclusion of my
partners, spouses, significant others, parents, legal guardians,
or other family members in therapy when deemed necessary by
myself or my therapist. I agree that these parties
will have to sign a separate Consent for Third-Party
Participation Agreement or may have to sign a separate
disclosure statement in order to participate in therapy.
13. I understand that should I choose to discontinue
therapy for more than sixty (60) days by not
communicating with Hedman Counseling,
PC or Rachael Rosner, my treatment will be
considered "terminated." I may be able to resume
therapy after the sixty (60) day
period by discussing my decision to resume therapy
services with HedmanCounseling, PC/Rachael
Rosner. Ability to resume therapy after sixty (60) days will
depend upon my therapist's availability and will be
within their sole discretion. This disclosure
statement will remain in effect should I
resume therapy if one (1) year has not elapsed since my
last session. However, I may be asked to provide
additional information to update my client
record. I understand "discontinuing therapy" means that I
have not had a session with my therapist for at least sixty
(60) days, unless otherwise agreed to in writing.
14. There is no guarantee that psychotherapy will yield positive
or intended results. Although every effort will be made to
provide a positive and healing experience, every therapeutic
experience is unique and varies from person to person. Results
achieved in a therapeutic relationship with one person are not a
guarantee of similar results with all clients.
15. I understand that my therapist may refer me to and/or expect
me to avail myself of outside supportive resources, including,
but not limited to, other health care professionals, as deemed
appropriate. A failure on my part to comply with
such recommendations may result in
termination of the therapeutic relationship. I
understand that my therapist will discuss this with me prior to
terminating the therapeutic relationship for this reason. It
is acknowledged that online or distance counseling is not a
substitute for medication given under the care of a psychiatrist
or doctor. I understand and agree that Rachael
Rosner is neither a psychiatrist nor a doctor and is
therefore not legally allowed to prescribe medications or to give
medical advice. It is further understood that online or
distance counseling is not appropriate if you are experiencing a
crisis or having suicidal or homicidal thoughts.
16. Because of the nature of therapy, I understand that my
therapeutic relationship has to be different from most other
relationships. In order to protect the integrity of the
counseling process the therapeutic relationship must remain
solely that of therapist and client. This means
that my therapist cannot
be my friend, cannot have any type of business
relationship with me other than the counseling
relationship (i.e. cannot hire me, lend to or borrow
from me; or trade or barter for services in exchange for
counseling); cannot have any kind of romantic or sexual
relationship with a former or current client, or any other people
close to a client, and cannot hold the role of counselor
to theirrelatives, friends, the relatives of friends,
people known socially, or business contacts.
17. I understand that should I cancel within
24 business hours of my appointment or fail to
show up for my scheduled appointment without
notice ("no-show"), my therapist has a right to charge my
credit card on file, or my account, for the full amount of
my session.
18. I also affirm, by signing this form, I am at least fifteen
(15) years old and consent to treatment and therapy services here
at Hedman Counseling, PC. In the event that I am the legal
guardian and/or custodial parent with the legal right to consent
to treatment for any minor child/ren who is under the age of
fifteen (15) and for whom I am requesting therapy services here
at Hedman Counseling, PC, I understand it
is Hedman Counseling, PC/Rachael Rosner's policy to
seek the consent of both parents/legal guardians. Further, in the
event of a custody or divorce dispute, I and the therapist must
obtain the consent from the other parent/legal guardian for my
minor child/ren's treatment in accordance with DORA policy.
If I am the non-custodial parent signing this consent form for my
minor child/ren's treatment in accordance with DORA's policy, I
understand that my access to my child/ren's treatment and client
record may be limited by court order.
In the event that I am over the age of twelve (12) but under the
age of fifteen (15) years old, I affirm that I am consenting to
treatment and psychotherapeutic services here at Hedman
Counseling, PC, and that I have been advised by Rachael
Rosner of the importance of involving my parents and/or
legal guardians, and that I have willingly signed the Voluntary
Consent for Psychotherapeutic Services form.
19. I understand that if I am consenting to treatment and therapy
services for my minor child/ren that my therapist will request
that I produce, in advance of commencing services
with Hedman Counseling, PC/Rachael Rosner, the Court
Order Custody Agreement and/or Parenting Plan that grants me the
authority to consent to mental health services for my minor child
and make therapeutic decisions on behalf of my minor
child/ren. I also understand that it
is Hedman Counseling, PC/Rachael Rosner's policy to
request and seek consent from both my minor child/ren's parents,
but that such consent does not supersede the Court Order Custody
Agreement and/or Parenting Plan. By signing this form, I
understand and consent to Hedman Counseling, PC/Rachael
Rosner's "No Secrets" in Custody Circumstances Policy as outlined
above. Further, I understand and agree to keep my therapist
informed of any proceedings or supplemental court orders that
affect my parenting rights, custody arrangements, and
decision-making authority. I understand that failing to provide
the Court Order Custody Agreement and/or Parenting Plan will
prohibit my therapist from providing therapy to my minor
child/ren. I understand that it is beyond the scope of my
therapist's practice to provide custody recommendations. Any
request for custody recommendations will be denied. A Court is
able to appoint professionals with the expertise to make such
recommendations.
20. By signing this form, I affirm that I am fully informed of
the therapy services I am requesting and
that HedmanCounseling, PC/Rachael Rosner is providing,
and grant my consent to receive such therapy services.
My signature below affirms that the preceding information has
been provided to me in writing by my primary therapist, or if I
am unable to read or have no written language, an oral
explanation accompanied the written copy. I understand my
rights as a client/patient and should I have any questions, I
will ask my therapist.