DISCLOSURE STATEMENT and INFORMED CONSENT
[Note: Colorado State law requires that all licensed and unlicensed psychotherapists provide all new clients with a “Disclosure Statement” which must contain information specified by the Psychologist Licensing Board.]
Welcome to my clinical psychology practice. I share the following information to help establish the clarity, understanding, and trust essential to a therapeutic relationship. Please read the following information carefully, as it contains important information about my practice and policies. Note any questions or concerns you have, and we can discuss them before beginning psychotherapy. After you sign this document, it will constitute a binding agreement between us.
The Process of Therapy/Evaluation: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek help. As a collaborative process, therapy requires your active efforts, honesty, and openness in order to achieve desired changes. I will periodically ask for your feedback on therapy and will expect you to respond openly and honestly. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, and so forth. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to have emotional reactions, such as emotional discomfort, anxiety, or anger. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Therapy may also result in decisions about making many different kinds of changes. Sometimes a decision that is positive for one family member is viewed negatively by another family member. Change will sometimes be easy and swift; other times it will be slow and even frustrating. There is no guarantee that therapy will yield the intended results.
Sometimes more than one approach can be helpful in dealing with a certain situation. You are entitled by law to receive information about the methods of therapy, the techniques used, the duration of therapy, if known, and the fee structure. During the course of therapy, I am likely to draw on various therapeutic approaches according, in part, to the problem that is being treated and my assessment of what will best benefit you. My approach tends to be emotionally
focused, experiential, humanistic, cognitive-behavioral, and family systems oriented. At times I may draw on other approaches. Within a reasonable period of time after the initiation of treatment, I will be able to offer you some initial impressions of what our work will include. You should also make your own assessment about whether you feel comfortable working with me. If you have any questions about the process of therapy, please let me know. I will always seek to answer your questions fully.
Ending Therapy: The most common reason for ending therapy is that a client’s concerns have been addressed to their satisfaction. Although you are free to end therapy or seek a second opinion from another therapist at any time, most clients find it helpful to have one or two “ending/termination sessions” to bring closure to therapy and discuss what has taken place during our time together. These “ending sessions” can be helpful in preventing future problems. Another scenario in which therapy ends is when a client’s challenges lie beyond the limits of my expertise or ability to help. I do not work with clients whose challenges, in my opinion, are beyond my ability. If this becomes apparent to me at any point, I would discuss this with you, offer you appropriate referrals, and end treatment.
Legal Disclosures: By law, all therapists in Colorado are required to disclose the following information.
• Rachael St.Claire’s Credentials & Degrees: Licensed Psychologist in the State of Colorado (License # PSY1546); Doctor of Psychology, Wright State University, School of Professional Psychology, 1988; Bachelor of Science in Psychology with Honors, University of Illinois, Champaigne-Urbana, 1980. Dr. St.Claire is a full member of the American Psychological Association. In addition to her private practice, she has worked as a full time clinical psychologist with the Kaiser Permanente Behavioral Health Department since 1992.
• Both personally and professionally, I am committed to the highest standards of ethical practice in my field. The information provided by clients during therapy sessions is legally confidential, except as provided in section 12-43-218 of the Colorado Mental Health Statue, and except for certain legal exceptions that are identified in my Confidentiality Form.
• In a professional relationship, sexual intimacy is never appropriate and should be reported to the board.
• The practice of psychotherapy in Colorado is regulated by the Department of Regulatory Agencies. If you should have a complaint about unethical conduct, you may contact the Grievance Board: Department of Regulatory Agencies, Colorado Mental Health Section, 1560 Broadway, Suite 1350, Denver, CO 80202. Phone: 303-894-7766.
Office Polices
Payment and Fees: You are expected to pay the standard fee of $125 per 55-minute session at each session, unless other arrangements have been made. If longer sessions occur, the fee will be prorated. Fees for additional time or services, including travel time, will be prorated at my regular fee. Such additional services may include, but are not limited to, consultation with other professionals, preparation of reports or correspondence, and phone calls lasting over 10 minutes. Any court appearances will be billed at $250 per hour. Acceptable forms of payment are cash or check. If your check is deposited with insufficient funds, you will be charged an additional $35 to cover bank fees. Please notify me if any problem arises during the course of therapy regarding your ability to make timely payments.
Overdue Payment: If your account is more than 30 days overdue and suitable arrangements have not been agreed to, I have the option of using legal means to secure payment, including collection agencies or small claims court. (If such legal action is necessary, the costs of bringing that proceeding will be included in the claim.)
Cancellation: Since your appointments involve the reservation of time specifically for you, a minimum of 24 hours’ notice is required for rescheduling or canceling an appointment. You will be charged the full fee for late cancellations or failure to keep your scheduled appointment with me. Repeated cancellations (more than two) without sufficient notice may result in the termination of therapy.
Insurance: Although I do not bill insurance companies directly, at your request I will provide you with a statement of services that you can then submit to your insurance company for reimbursement. Please be aware that submitting an invoice for reimbursement carries a certain amount of risk, as I cannot control how your information is used once submitted. Not all therapeutic issues are reimbursable; it is your responsibility to verify the specifics of your coverage.
Phone Numbers: If you need to contact me, please leave a message for me at 720-220-5770. I will return your call as soon as possible during my business hours (8 am—5 pm, Monday—Friday). Although I try to be prompt in responding to messages, due to having a very busy practice, sometimes I return calls on the following business day. I check my messages a few times a day, but never during the nighttime. I check my messages much less frequently on weekends, holidays, and when I am out of town. I return weekend calls on Monday, unless Monday is a holiday.
Emergencies: Due to the nature of my work, I am often not immediately available by telephone. I do, however, check my phone periodically for messages. Therapeutic calls are billed pro-rated at the regular fee. If you need to talk to someone immediately, please call 911 or the 24-hour National Crisis Hotline at 1-800-273-TALK, or go to your nearest hospital emergency room.
Email, Texting, and Online Social Networking Policy: Because it is not possible to guarantee the confidentiality of email communications, please use discretion in deciding whether to communicate with me via email. I cannot be held responsible for any information lost in transit or viewed by a third party. Email should only be used for brief, general questions. Hence, emergencies, therapeutic issues, sensitive personal information, and cancellations should all be communicated to me over the telephone or in person. I do not communicate with clients by text messages, and ask that you do not use this method of communication with me either. Likewise, I do not communicate with clients via online social networking sites (e.g., Facebook, Twitter, etc.).
Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters that may be of a sensitive and confidential nature, it is agreed that should you be involved in legal proceedings, neither you nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the therapy records be requested.
Please read the “Disclosure Statement and Informed Consent” document before signing below.
My signature below affirms my informed and voluntary consent to enter therapy (and/or have my child/ren enter therapy). I affirm that prior to becoming a patient of Rachael St.Claire PsyD, she gave me sufficient information to understand the nature of therapy, including the possible risks and benefits. I understand her office policies and procedures. I have had an opportunity to ask questions and have had my questions answered satisfactorily. I understand that I can ask questions and raise concerns about the treatment at any time.
_____________________________________ _____________
Signature Date
_____________________________________ _____________
Signature Date
Confidentiality: Trust is the foundation of a good therapeutic relationship. I strive to provide a safe atmosphere where you can honestly explore very personal issues. All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. You should be aware of the following issues about confidentiality.
Consultation and Video Recording of Sessions: In order to provide the best possible therapy treatment, it is common for therapists to periodically record video of therapy sessions; I make particular use of this when I work with couples. The purpose of recording therapy sessions is to enhance the effectiveness of therapy by providing me with another way to review our therapy sessions. I also consult with regularly with other professionals concerning my clients; this consultation sometimes includes reviewing recorded portions of therapy. This practice of consultation often enhances the effectiveness of therapy, as “two sets of eyes are often better than one.” All professionals with whom I consult are bound by the same laws respecting your confidentiality.
Consultation with Psychiatrists: If you are also being seen by a psychiatrist, it is my policy to require an authorization for me to exchange information regarding your medical and mental health treatment. If this is not a suitable arrangement for you, I will offer referrals to you to be seen in a different practice.
Some of the circumstances where disclosure is required by the law are as follows:
• If I have a reasonable suspicion of the abuse or neglect of a minor child, dependent, or vulnerable adult, I am required by law to make a report to the appropriate protective agencies in Colorado.
• If a patient threatens grave bodily harm to others, I have a legal duty to warn those threatened, and to make a report to law enforcement.
• If a patient is at risk of causing grave bodily harm to themselves, including suicide, I have a duty to take action to insure the protection of the patient. This may include involuntary hospitalization, a report to law enforcement, and contacting others who can take action to protect the patient.
• Disclosure may be required pursuant to legal proceedings. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the therapy records and/or testimony by Rachael St.Claire PsyD. Also, if you are on probation/parole, it may be legally required that I share information with various individuals appointed by the courts.
In couples and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. I will use clinical judgment when revealing such information. If you reveal to me a “secret” that you refuse to disclose to the others and that puts me, by my knowing the “secret”, in a position of hurting my honest relationship with others in the couple/family, I may terminate our therapy agreement. I will not release records to any outside party unless so authorized to do so, in writing, by every member of the couple or family in treatment able to execute a waiver.
If I see a child under the age of consent (younger than 16), all custodial parents have a right to information shared in the session. Custodial parents should be aware that exercising this right may be detrimental to the therapeutic process, and so may wish to allow confidentiality between the child and therapist. Considering all of the above exclusions, upon your request I will release information to any agency/person you specify unless I conclude that releasing such information might be harmful.
There is the possibility that you may see someone you know leaving my office see me while out in the community. Although I may greet you cordially, I never acknowledge working therapeutically with anyone without written permission.
By signing below, I affirm that I have read and understand the nature of confidentiality in therapy as set forth above. I also give my consent to allow my therapy sessions with Rachael St.Claire PsyD to be recorded by video. I understand that any supervisor, therapist, or therapist-in-training who observes the recording of my therapy session is under the same confidentiality requirements as my therapist. Furthermore, I understand that in the unlikely event that any supervisor, therapist, or therapist-in-training knows me from another non-therapy setting, he/she will immediately leave the consultation session and will not observe, seek, or be given any information regarding myself or my treatment. I understand that I may withdraw this consent to record video at any time (in writing). I have had an opportunity to ask questions and have had my questions answered satisfactorily.
Client Signature: ________________________________ Date: __________
Client Signature: ________________________________ Date: __________
[Note: Colorado State law requires that all licensed and unlicensed psychotherapists provide all new clients with a “Disclosure Statement” which must contain information specified by the Psychologist Licensing Board.]
Welcome to my clinical psychology practice. I share the following information to help establish the clarity, understanding, and trust essential to a therapeutic relationship. Please read the following information carefully, as it contains important information about my practice and policies. Note any questions or concerns you have, and we can discuss them before beginning psychotherapy. After you sign this document, it will constitute a binding agreement between us.
The Process of Therapy/Evaluation: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek help. As a collaborative process, therapy requires your active efforts, honesty, and openness in order to achieve desired changes. I will periodically ask for your feedback on therapy and will expect you to respond openly and honestly. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, and so forth. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to have emotional reactions, such as emotional discomfort, anxiety, or anger. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Therapy may also result in decisions about making many different kinds of changes. Sometimes a decision that is positive for one family member is viewed negatively by another family member. Change will sometimes be easy and swift; other times it will be slow and even frustrating. There is no guarantee that therapy will yield the intended results.
Sometimes more than one approach can be helpful in dealing with a certain situation. You are entitled by law to receive information about the methods of therapy, the techniques used, the duration of therapy, if known, and the fee structure. During the course of therapy, I am likely to draw on various therapeutic approaches according, in part, to the problem that is being treated and my assessment of what will best benefit you. My approach tends to be emotionally
focused, experiential, humanistic, cognitive-behavioral, and family systems oriented. At times I may draw on other approaches. Within a reasonable period of time after the initiation of treatment, I will be able to offer you some initial impressions of what our work will include. You should also make your own assessment about whether you feel comfortable working with me. If you have any questions about the process of therapy, please let me know. I will always seek to answer your questions fully.
Ending Therapy: The most common reason for ending therapy is that a client’s concerns have been addressed to their satisfaction. Although you are free to end therapy or seek a second opinion from another therapist at any time, most clients find it helpful to have one or two “ending/termination sessions” to bring closure to therapy and discuss what has taken place during our time together. These “ending sessions” can be helpful in preventing future problems. Another scenario in which therapy ends is when a client’s challenges lie beyond the limits of my expertise or ability to help. I do not work with clients whose challenges, in my opinion, are beyond my ability. If this becomes apparent to me at any point, I would discuss this with you, offer you appropriate referrals, and end treatment.
Legal Disclosures: By law, all therapists in Colorado are required to disclose the following information.
• Rachael St.Claire’s Credentials & Degrees: Licensed Psychologist in the State of Colorado (License # PSY1546); Doctor of Psychology, Wright State University, School of Professional Psychology, 1988; Bachelor of Science in Psychology with Honors, University of Illinois, Champaigne-Urbana, 1980. Dr. St.Claire is a full member of the American Psychological Association. In addition to her private practice, she has worked as a full time clinical psychologist with the Kaiser Permanente Behavioral Health Department since 1992.
• Both personally and professionally, I am committed to the highest standards of ethical practice in my field. The information provided by clients during therapy sessions is legally confidential, except as provided in section 12-43-218 of the Colorado Mental Health Statue, and except for certain legal exceptions that are identified in my Confidentiality Form.
• In a professional relationship, sexual intimacy is never appropriate and should be reported to the board.
• The practice of psychotherapy in Colorado is regulated by the Department of Regulatory Agencies. If you should have a complaint about unethical conduct, you may contact the Grievance Board: Department of Regulatory Agencies, Colorado Mental Health Section, 1560 Broadway, Suite 1350, Denver, CO 80202. Phone: 303-894-7766.
Office Polices
Payment and Fees: You are expected to pay the standard fee of $125 per 55-minute session at each session, unless other arrangements have been made. If longer sessions occur, the fee will be prorated. Fees for additional time or services, including travel time, will be prorated at my regular fee. Such additional services may include, but are not limited to, consultation with other professionals, preparation of reports or correspondence, and phone calls lasting over 10 minutes. Any court appearances will be billed at $250 per hour. Acceptable forms of payment are cash or check. If your check is deposited with insufficient funds, you will be charged an additional $35 to cover bank fees. Please notify me if any problem arises during the course of therapy regarding your ability to make timely payments.
Overdue Payment: If your account is more than 30 days overdue and suitable arrangements have not been agreed to, I have the option of using legal means to secure payment, including collection agencies or small claims court. (If such legal action is necessary, the costs of bringing that proceeding will be included in the claim.)
Cancellation: Since your appointments involve the reservation of time specifically for you, a minimum of 24 hours’ notice is required for rescheduling or canceling an appointment. You will be charged the full fee for late cancellations or failure to keep your scheduled appointment with me. Repeated cancellations (more than two) without sufficient notice may result in the termination of therapy.
Insurance: Although I do not bill insurance companies directly, at your request I will provide you with a statement of services that you can then submit to your insurance company for reimbursement. Please be aware that submitting an invoice for reimbursement carries a certain amount of risk, as I cannot control how your information is used once submitted. Not all therapeutic issues are reimbursable; it is your responsibility to verify the specifics of your coverage.
Phone Numbers: If you need to contact me, please leave a message for me at 720-220-5770. I will return your call as soon as possible during my business hours (8 am—5 pm, Monday—Friday). Although I try to be prompt in responding to messages, due to having a very busy practice, sometimes I return calls on the following business day. I check my messages a few times a day, but never during the nighttime. I check my messages much less frequently on weekends, holidays, and when I am out of town. I return weekend calls on Monday, unless Monday is a holiday.
Emergencies: Due to the nature of my work, I am often not immediately available by telephone. I do, however, check my phone periodically for messages. Therapeutic calls are billed pro-rated at the regular fee. If you need to talk to someone immediately, please call 911 or the 24-hour National Crisis Hotline at 1-800-273-TALK, or go to your nearest hospital emergency room.
Email, Texting, and Online Social Networking Policy: Because it is not possible to guarantee the confidentiality of email communications, please use discretion in deciding whether to communicate with me via email. I cannot be held responsible for any information lost in transit or viewed by a third party. Email should only be used for brief, general questions. Hence, emergencies, therapeutic issues, sensitive personal information, and cancellations should all be communicated to me over the telephone or in person. I do not communicate with clients by text messages, and ask that you do not use this method of communication with me either. Likewise, I do not communicate with clients via online social networking sites (e.g., Facebook, Twitter, etc.).
Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters that may be of a sensitive and confidential nature, it is agreed that should you be involved in legal proceedings, neither you nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the therapy records be requested.
Please read the “Disclosure Statement and Informed Consent” document before signing below.
My signature below affirms my informed and voluntary consent to enter therapy (and/or have my child/ren enter therapy). I affirm that prior to becoming a patient of Rachael St.Claire PsyD, she gave me sufficient information to understand the nature of therapy, including the possible risks and benefits. I understand her office policies and procedures. I have had an opportunity to ask questions and have had my questions answered satisfactorily. I understand that I can ask questions and raise concerns about the treatment at any time.
_____________________________________ _____________
Signature Date
_____________________________________ _____________
Signature Date
Confidentiality: Trust is the foundation of a good therapeutic relationship. I strive to provide a safe atmosphere where you can honestly explore very personal issues. All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. You should be aware of the following issues about confidentiality.
Consultation and Video Recording of Sessions: In order to provide the best possible therapy treatment, it is common for therapists to periodically record video of therapy sessions; I make particular use of this when I work with couples. The purpose of recording therapy sessions is to enhance the effectiveness of therapy by providing me with another way to review our therapy sessions. I also consult with regularly with other professionals concerning my clients; this consultation sometimes includes reviewing recorded portions of therapy. This practice of consultation often enhances the effectiveness of therapy, as “two sets of eyes are often better than one.” All professionals with whom I consult are bound by the same laws respecting your confidentiality.
Consultation with Psychiatrists: If you are also being seen by a psychiatrist, it is my policy to require an authorization for me to exchange information regarding your medical and mental health treatment. If this is not a suitable arrangement for you, I will offer referrals to you to be seen in a different practice.
Some of the circumstances where disclosure is required by the law are as follows:
• If I have a reasonable suspicion of the abuse or neglect of a minor child, dependent, or vulnerable adult, I am required by law to make a report to the appropriate protective agencies in Colorado.
• If a patient threatens grave bodily harm to others, I have a legal duty to warn those threatened, and to make a report to law enforcement.
• If a patient is at risk of causing grave bodily harm to themselves, including suicide, I have a duty to take action to insure the protection of the patient. This may include involuntary hospitalization, a report to law enforcement, and contacting others who can take action to protect the patient.
• Disclosure may be required pursuant to legal proceedings. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the therapy records and/or testimony by Rachael St.Claire PsyD. Also, if you are on probation/parole, it may be legally required that I share information with various individuals appointed by the courts.
In couples and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. I will use clinical judgment when revealing such information. If you reveal to me a “secret” that you refuse to disclose to the others and that puts me, by my knowing the “secret”, in a position of hurting my honest relationship with others in the couple/family, I may terminate our therapy agreement. I will not release records to any outside party unless so authorized to do so, in writing, by every member of the couple or family in treatment able to execute a waiver.
If I see a child under the age of consent (younger than 16), all custodial parents have a right to information shared in the session. Custodial parents should be aware that exercising this right may be detrimental to the therapeutic process, and so may wish to allow confidentiality between the child and therapist. Considering all of the above exclusions, upon your request I will release information to any agency/person you specify unless I conclude that releasing such information might be harmful.
There is the possibility that you may see someone you know leaving my office see me while out in the community. Although I may greet you cordially, I never acknowledge working therapeutically with anyone without written permission.
By signing below, I affirm that I have read and understand the nature of confidentiality in therapy as set forth above. I also give my consent to allow my therapy sessions with Rachael St.Claire PsyD to be recorded by video. I understand that any supervisor, therapist, or therapist-in-training who observes the recording of my therapy session is under the same confidentiality requirements as my therapist. Furthermore, I understand that in the unlikely event that any supervisor, therapist, or therapist-in-training knows me from another non-therapy setting, he/she will immediately leave the consultation session and will not observe, seek, or be given any information regarding myself or my treatment. I understand that I may withdraw this consent to record video at any time (in writing). I have had an opportunity to ask questions and have had my questions answered satisfactorily.
Client Signature: ________________________________ Date: __________
Client Signature: ________________________________ Date: __________