INFORMED CONSENT
Informed Consent PDF
Psychological Services:
Welcome. While I cannot assure you of success, I can tell you that psychotherapy has benefitted many people who have undertaken it with sincerity and commitment. Our first few sessions will involve an evaluation of your needs, the setting of goals, and a treatment plan. We will both be evaluating whether or not we can work together well. At any time during the course of our work together, I will be pleased to provide you with information about my professional methods, techniques, and interventions. After our first few sessions, I may be able to judge approximately how long your psychotherapy should take. Feel free to ask questions at any time. As we work together, periodically we will take time to evaluate the effectiveness of your therapy using your and my observations, any record-keeping you are asked to do, and various assessment instruments. My sessions generally start on the hour and last from 50-60 minutes. I will wait 15 minutes for your arrival to a session without hearing from you before I may leave. I do sometimes run late starting sessions due to differing circumstances that may include the demands in a session preceding yours. Feel free to ring the doorbell if you are kept waiting.
Some Risks:
• For some people, psychotherapy may involve emotional intensity or discomfort.
• Therapy can disrupt current relationships – some relationships will evolve as changes and insight develop whereas others may end.
• It is also possible that positive and negative feelings may develop for the therapist that are confusing, and those feelings arise from the unique relationship between therapist and client. Those feelings are normal and important to discuss in session. Feel free to discuss any feelings you have with me.
My Qualifications:
Education: University of Colorado at Colorado Springs, Colorado Springs, Colorado
Degree: Bachelor of Arts, Psychology 1998
University of Colorado at Colorado Springs, Colorado Springs, Colorado
Degree: Master of Arts, Psychology 2001
Colorado Springs School of Professional Psychology (now University of the Rockies), Colorado Springs, Colorado
Degree: Doctor of Psychology (PsyD), Clinical Psychology 2009
Certifications: Eye Movement Desensitization Reprocessing Therapy
Cognitive Processing Therapy
Prolonged Exposure Therapy
Client’s Rights:
As my client, you have the right to:
• Confidentiality
o State law and professional ethics protect the confidential nature of the therapeutic relationship. Without your consent, I will not share with others what you tell me. You should be aware that I do not employ an answering or billing service; however, my business account is managed by a retired Air Force Dentist who is trained and compliant in medical confidentiality and HIPPAA policies. He does not have access to your treatment records. I belong to a cloud-based platform for therapists, iCouch.me, that allows me to have a largely paperless office. The site has security measures, and I identify clients only by initials in my documentation, on my calendar, in my contact list, and in my accounting. Should the site be violated, the only identifying information other than initials, and only if you give permission, would be your email address and/or telephone numbers. The site will allow you to schedule appointments and to use secure video chat and messaging, if you decide you wish to join. Exceptions to the imperative to maintain confidentiality are mandated by state law which requires that I report:
Your intention to seriously harm yourself.
Your intention to seriously harm others.
Abuse or neglect of a minor.
Abuse or neglect of an elder.
Abuse or neglect of an at-risk adult (one who is disabled in some way).
Court order
Your plan to commit a crime.
Sexual abuse perpetrated upon you when you were young.
• Continuance in therapy
o Generally, you can count on continuing in therapy unless you fail to appear for appointments without canceling on 3 consecutive occasions, or if you do not appear for an appointment for at least 30 days. At that time, your file will be closed. You are welcome to return at any time; however, it may be necessary for you to see another provider if I have a full case load and cannot accommodate you. The other condition under which you may be referred to another provider are if we, together, decide that you are not making progress or benefitting from therapy.
o Immediate termination of therapy. You acknowledge and agree that the therapeutic relationship will be immediately terminated if the following events occur:
1. You attempt to end your own life.
2. You threaten physical harm to me as your therapist, to my family, or my property.
3. You physically harm me as your therapist or you physically harm my family, my property, or another person.
• Treatment Summary
o You may get a written summary of your treatment with me if you wish.
• Grievance
o Sexual intimacy between a client and therapist is not part of any recognized therapy. Should it or any other behavior on my part occur about which you have questions that you feel you are not comfortable discussing with me, you have the right to consult the Colorado Department of Regulatory Agencies, Board of Examiners in Psychology (303) 894-7800.
Emergency:
This practice is a sole provider practice rather than a clinic and is not equipped as a crisis center. In cases of emergency, call 911 for help or proceed immediately to the nearest Emergency Room if you feel you are at imminent risk of doing harm to yourself or another. You may also choose to call a crisis hotline before taking these steps.
Pike’s Peak Crisis Hotline 844.493.8255
Pike’s Peak Mental Health 719.635.7000
Peak View 719.444.8484
Military One Source 800.342.9647
Aspen Pointe has a walk-in crisis help center at 115 South Park Drive in Colorado Springs. As my client, you have been provided with a Distress Plan to complete that includes the information just given along with preliminary steps to try and calm your distress. You should keep a copy of that plan in a place you can always easily reach and attempt to follow those steps, if you can. A copy of that plan form, should you lose yours, is available on my website at www.intentionalenrichment.com under the “In Crisis” tab.
Out of Session Contact:
In today’s world, the opportunities for contact have broadened to include avenues unimagined just a few decades ago. These methods have encouraged us to seek expect immediacy and loosening of restrictions regarding day and time. For clarity’s sake, I have some policies about out-of-session contact, including by text and e-mail.
Please remember that my practice is not structured for crisis support. On this form,, on your Distress Plan, and on my website are hotline numbers and emergency walk-in services available to you if you are in acute distress and fear you might harm yourself or anyone else.
• Email. I restricted email contact to people who are considering whether to embark on therapy with me. Email is non-secure. I believe a risk to your confidentiality and privacy exists. That risk to you as my client is unacceptable to me. Therefore, if I am engaged in therapy with you, I will not respond to any emails and discourage you from contacting me by that method.
• Telephone. I will generally check my voice mail messages between 9:00 and 11:00 a.m. on Monday through Thursday. I do not generally check my voice mail messages after 5:00 p.m. or on Friday, Saturday, Sunday, or on holidays. If you leave a voice mail message for me on Thursday, you may not get a return call until Monday. For example, if you call after I check messages at 9:00-11:00 a.m. on Tuesday, you may not receive a return call until Thursday because I may not receive your message until I check on Wednesday. I will return your call as soon as I can upon receiving your message, but no later than 24 hours after I receive your message rather than 24 hours after you leave one.
• Text. Without express agreement between us, please do not send text messages. They are non-secure and not reliable – we’ve all had incidents where texts sent were not received in a timely manner or at all due to dead spots, glitches, or disruptions in service. For this reason, I ask that you exclude text messages as a way of reaching me. Notification of running late, last minute cancellations due to weather or illness, and other information and questions should be by telephone contact or voice mail message. If you must send a message, and you have an account at my invitation, please use the secure messaging through iCouch.me.
• Unexpected Encounters. It is entirely possible that we will unexpectedly meet each other away from my office. In that case, to protect your privacy and confidentiality, I will not greet you. You are entirely welcome to approach me, and I will be delighted to see you. The decision to publicly acknowledge that you know me must rest in your hands.
Client’s Responsibilities:
As a client you have the following responsibilities:
• Cancel an appointment at least 24 hours beforehand by calling (609) 424-9237.
• Pay fees as agreed.
• Fulfill any therapy homework to which you agree.
I have read and understand the above information. I agree to the stated conditions.
___________________________________________ ______________________
Signature of Client or Guardian Date
__________________________________________ _____________________
Signature of Therapist Date
Welcome. While I cannot assure you of success, I can tell you that psychotherapy has benefitted many people who have undertaken it with sincerity and commitment. Our first few sessions will involve an evaluation of your needs, the setting of goals, and a treatment plan. We will both be evaluating whether or not we can work together well. At any time during the course of our work together, I will be pleased to provide you with information about my professional methods, techniques, and interventions. After our first few sessions, I may be able to judge approximately how long your psychotherapy should take. Feel free to ask questions at any time. As we work together, periodically we will take time to evaluate the effectiveness of your therapy using your and my observations, any record-keeping you are asked to do, and various assessment instruments. My sessions generally start on the hour and last from 50-60 minutes. I will wait 15 minutes for your arrival to a session without hearing from you before I may leave. I do sometimes run late starting sessions due to differing circumstances that may include the demands in a session preceding yours. Feel free to ring the doorbell if you are kept waiting.
Some Risks:
• For some people, psychotherapy may involve emotional intensity or discomfort.
• Therapy can disrupt current relationships – some relationships will evolve as changes and insight develop whereas others may end.
• It is also possible that positive and negative feelings may develop for the therapist that are confusing, and those feelings arise from the unique relationship between therapist and client. Those feelings are normal and important to discuss in session. Feel free to discuss any feelings you have with me.
My Qualifications:
Education: University of Colorado at Colorado Springs, Colorado Springs, Colorado
Degree: Bachelor of Arts, Psychology 1998
University of Colorado at Colorado Springs, Colorado Springs, Colorado
Degree: Master of Arts, Psychology 2001
Colorado Springs School of Professional Psychology (now University of the Rockies), Colorado Springs, Colorado
Degree: Doctor of Psychology (PsyD), Clinical Psychology 2009
Certifications: Eye Movement Desensitization Reprocessing Therapy
Cognitive Processing Therapy
Prolonged Exposure Therapy
Client’s Rights:
As my client, you have the right to:
• Confidentiality
o State law and professional ethics protect the confidential nature of the therapeutic relationship. Without your consent, I will not share with others what you tell me. You should be aware that I do not employ an answering or billing service; however, my business account is managed by a retired Air Force Dentist who is trained and compliant in medical confidentiality and HIPPAA policies. He does not have access to your treatment records. I belong to a cloud-based platform for therapists, iCouch.me, that allows me to have a largely paperless office. The site has security measures, and I identify clients only by initials in my documentation, on my calendar, in my contact list, and in my accounting. Should the site be violated, the only identifying information other than initials, and only if you give permission, would be your email address and/or telephone numbers. The site will allow you to schedule appointments and to use secure video chat and messaging, if you decide you wish to join. Exceptions to the imperative to maintain confidentiality are mandated by state law which requires that I report:
Your intention to seriously harm yourself.
Your intention to seriously harm others.
Abuse or neglect of a minor.
Abuse or neglect of an elder.
Abuse or neglect of an at-risk adult (one who is disabled in some way).
Court order
Your plan to commit a crime.
Sexual abuse perpetrated upon you when you were young.
• Continuance in therapy
o Generally, you can count on continuing in therapy unless you fail to appear for appointments without canceling on 3 consecutive occasions, or if you do not appear for an appointment for at least 30 days. At that time, your file will be closed. You are welcome to return at any time; however, it may be necessary for you to see another provider if I have a full case load and cannot accommodate you. The other condition under which you may be referred to another provider are if we, together, decide that you are not making progress or benefitting from therapy.
o Immediate termination of therapy. You acknowledge and agree that the therapeutic relationship will be immediately terminated if the following events occur:
1. You attempt to end your own life.
2. You threaten physical harm to me as your therapist, to my family, or my property.
3. You physically harm me as your therapist or you physically harm my family, my property, or another person.
• Treatment Summary
o You may get a written summary of your treatment with me if you wish.
• Grievance
o Sexual intimacy between a client and therapist is not part of any recognized therapy. Should it or any other behavior on my part occur about which you have questions that you feel you are not comfortable discussing with me, you have the right to consult the Colorado Department of Regulatory Agencies, Board of Examiners in Psychology (303) 894-7800.
Emergency:
This practice is a sole provider practice rather than a clinic and is not equipped as a crisis center. In cases of emergency, call 911 for help or proceed immediately to the nearest Emergency Room if you feel you are at imminent risk of doing harm to yourself or another. You may also choose to call a crisis hotline before taking these steps.
Pike’s Peak Crisis Hotline 844.493.8255
Pike’s Peak Mental Health 719.635.7000
Peak View 719.444.8484
Military One Source 800.342.9647
Aspen Pointe has a walk-in crisis help center at 115 South Park Drive in Colorado Springs. As my client, you have been provided with a Distress Plan to complete that includes the information just given along with preliminary steps to try and calm your distress. You should keep a copy of that plan in a place you can always easily reach and attempt to follow those steps, if you can. A copy of that plan form, should you lose yours, is available on my website at www.intentionalenrichment.com under the “In Crisis” tab.
Out of Session Contact:
In today’s world, the opportunities for contact have broadened to include avenues unimagined just a few decades ago. These methods have encouraged us to seek expect immediacy and loosening of restrictions regarding day and time. For clarity’s sake, I have some policies about out-of-session contact, including by text and e-mail.
Please remember that my practice is not structured for crisis support. On this form,, on your Distress Plan, and on my website are hotline numbers and emergency walk-in services available to you if you are in acute distress and fear you might harm yourself or anyone else.
• Email. I restricted email contact to people who are considering whether to embark on therapy with me. Email is non-secure. I believe a risk to your confidentiality and privacy exists. That risk to you as my client is unacceptable to me. Therefore, if I am engaged in therapy with you, I will not respond to any emails and discourage you from contacting me by that method.
• Telephone. I will generally check my voice mail messages between 9:00 and 11:00 a.m. on Monday through Thursday. I do not generally check my voice mail messages after 5:00 p.m. or on Friday, Saturday, Sunday, or on holidays. If you leave a voice mail message for me on Thursday, you may not get a return call until Monday. For example, if you call after I check messages at 9:00-11:00 a.m. on Tuesday, you may not receive a return call until Thursday because I may not receive your message until I check on Wednesday. I will return your call as soon as I can upon receiving your message, but no later than 24 hours after I receive your message rather than 24 hours after you leave one.
• Text. Without express agreement between us, please do not send text messages. They are non-secure and not reliable – we’ve all had incidents where texts sent were not received in a timely manner or at all due to dead spots, glitches, or disruptions in service. For this reason, I ask that you exclude text messages as a way of reaching me. Notification of running late, last minute cancellations due to weather or illness, and other information and questions should be by telephone contact or voice mail message. If you must send a message, and you have an account at my invitation, please use the secure messaging through iCouch.me.
• Unexpected Encounters. It is entirely possible that we will unexpectedly meet each other away from my office. In that case, to protect your privacy and confidentiality, I will not greet you. You are entirely welcome to approach me, and I will be delighted to see you. The decision to publicly acknowledge that you know me must rest in your hands.
Client’s Responsibilities:
As a client you have the following responsibilities:
• Cancel an appointment at least 24 hours beforehand by calling (609) 424-9237.
• Pay fees as agreed.
• Fulfill any therapy homework to which you agree.
I have read and understand the above information. I agree to the stated conditions.
___________________________________________ ______________________
Signature of Client or Guardian Date
__________________________________________ _____________________
Signature of Therapist Date
