Disclosure Statement

YOUR RIGHTS AS A CLIENT

The practice of both licensed and unlicensed persons in the field of psychotherapy is regulated by the state of Colorado. Any Questions or complaints regarding the practice of mental health may be directed to the Mental Health Grievance Board, 1560 Broadway, Suite 1370, Denver, CO 80202, 303-894-7766. You are entitled to receive information about methods of therapy, techniques used, the duration of therapy, if known, and fee structure. You are also to be informed of the therapist’s degrees, credentials, and licenses.

You may seek a second opinion from a therapist or terminate therapy at any time.

You should know that in a professional relationship, sexual intimacy is never appropriate and should be reported to the Grievance Board.

You should understand that information provided by you during therapy is confidential in most circumstances.

CONFIDENTIALITY

Matters regarding your psychotherapy will be kept confidential except in the following circumstances: You sign a release of information giving permission to release information to a specific individual or agency, child abuse; you are an imminent danger to self or others, or in the case of the subpoena of records. In addition, I consult with and am supervised by a Supervisor, Consultant, and a Supervisee Group.  Any information shared is kept confidential. From time to time, I also consult with other colleagues, but in this circumstance, Clients are not identified by name. I also have an administrative assistant who assists me with my billing. Credit Card payments must be made through PayPal and your signature below constitutes you giving permission for such services. When fees for services are not paid in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, and case notes) is not disclosed. If a debt remains unpaid it may be reported to credit agencies, and the Client’s credit report may state the amount owed, time frame, and the name of the provider. The Client is responsible for the original bill, service charges, collection fees as well as additional costs that are incurred as a result of the collection process. Your signature below constitutes you giving permission for such consultations and services.

FEES AND PAYMENTS

I offer each Client a complimentary twenty-min. (20-min.) in office or by telephone initial consultation at no charge. Your first New Client appointment is fifty-minutes (45-50 min.) and is $108.00. The charges for services are is $64.00 for a thirty-minute (25-30 min.) appointment, $108.00 for a regular full fifty-minute (45-50 min.) appointment, and $194.00 for a ninety-minute (85-90 min.) appointment. In order to ensure that appointments begin and end on time, payment is due at the beginning of each appointment. Personal Check, Cash, VISA, Master Card, Discover, and American Express are accepted. Credit Card Payments must be made through PayPal. Billing occurs around the 1st and the 15th of every month. There is an $8.00 administrative fee applied per billing cycle for those who require billing. Payment must be received at time of service to receive a $4.00- $16.00 discount.

Payments received more than thirty days after the date due are subject to 19.8 annual percentage service charge calculated on a monthly rate of 1.65% of the remaining balance. Delinquent bills will be turned over to a collection agency. The patient is responsible for the original bill, service charges, collection fees as well as any legal costs that are incurred as a result of the collection process.

CANCELLATIONS

Your appointment time reserves my time for you. Should you need to cancel or reschedule your appointment time, I request that you provide at least 48-hours notice or you will be charged the regular full rate ($108.00) for the missed appointment. Two missed appointments in a row or frequent patterns of missed appointments are grounds for termination as a client and will be discuss with you in such case.

Effective psychotherapy does take a commitment on both sides. It has been my experience over the years that the more consistent (and sometimes frequent) the client is in attending their appointments, the greater and quicker the progress. In fact, some clients who have been unable to make it to the office will arrange to have their session over the telephone.

REPORTS AND PHONE CALLS

There is no charge for brief calls (lasting 5-minutes or less). There will be a $2.00- $2.16 per minute charge for all telephones calls other than brief calls (lasting 5-minutes or less) concerning rescheduling appointments, confirming appointments, etc.  Reports requested by insurance companies, physicians, etc. will not be released without your permission. Charges for reports will be prorated based on $108.00 per 45-50 minute hour ($2.00- $2.16 min). There are no discounts applied to reports and telephone calls that are not scheduled appointments.

MY AVAILABILITY AND VOICE MESSAGING

I am available to receive and return phone calls during my regular business hours (Monday- Thursday, 9 am- 3 pm). I pick up my messages every hour during regular business hours. All calls are retrieved and returned during regular business hours. There will be a $2.00- $2.16 per minute charge for all telephones calls other than brief calls (lasting 5-minutes or less) concerning rescheduling appointments, confirming appointments, etc. Please be aware that there are no discounts applied to telephone calls that are not scheduled appointments.

After Hours Emergencies: The hours outside my office hours are my time to spend with my family and friends and I use this time to restore so I can be of greatest resource for you. I do not check my voice mail or email during this time. I am not available after my usual business hours for emergencies and do not offer paging services. I do check my messages Monday- Thursday between 9:00 AM and 3:00 PM and I am usually available to speak with you on the telephone (or schedule a time we can talk). There will be a $2.00- $2.16 per minute charge for all telephones calls other than brief calls (lasting 5-minutes or less) concerning rescheduling appointments, confirming appointments, etc. Leave a message on my voice mail (303-241-1848) and I will call you back as soon as I retrieve the message. For after-hours emergencies or if you need immediate assistance call 911, your local mental health center, your medical group, hospital, or your primary care physician.

If you believe you may require contact outside of my office hours, I may not be the appropriate therapist for you and can offer you a referral.

Vacations: I will give you reasonable notice before I go on vacation. I usually take six to eight weeks of vacation a year. You will not be charged for sessions during this time. I will give you those dates with sufficient notice so that you can plan your time away in order to insure continuity of your process. When I am out of town or unavailable, contact your local mental health center, your medical group, hospital, your primary care physician or call 911 for assistance if you feel the need to see someone in my absence. However, if you feel that you will need continuing treatment during this time, I will help you make arrangements ahead of time with another therapist.

TERMINATION OF THERAPY

I support all termination, for whatever reason. When you are ready to leave, I would like to help you leave me well. In order for you to do this all you need to do is give me advance notice. Several weeks are sufficient, although some long-term Clients let me know several months in advance. When leaving is handled in this way, it often turns out to be the most productive time in therapy for clients. Even if you are not able to give me advance notice, I will still do my best to help you leave well.

Office Policies and Procedures

The initial appointment with Rebecca Armstrong C.C.Ht. consists of a twenty-minute in-office consultation at no charge, where Rebecca will take a brief history, discuss your goals for your work together, answer your questions, and determine whether this type of therapy is appropriate or to refer you to another health care professional. If you are accepted as a client, Rebecca Armstrong C.C.Ht. will explain the general process given her experience (all clients’ progress at their own pace and your results will be determined by your commitment to your own healing and level of participation) for you to achieve your desired goal. If accepted as a client you will be asked to commit to the full process of your healing before experiencing your first appointment. Although this therapy can produce rapid results it is not Short-term Therapy. Rebecca requires a full commitment from her clients before beginning the healing process.

Effective therapy usually costs more than money. Psychotherapy is a professional service that involves a relationship with a practitioner who is there solely to support you as you experience your own healing, empowerment, and resource development.  A self-help book or an occasional workshop will cost you much less in time and money than psychotherapy.   However, studies have indicated that although education or Short-term Therapy (such as a workshop or a book) can be extremely helpful (particularly for people who are already in therapy), clients report better results when they participate in long-term process.

So, you need to decide whether you are ready to invest a certain amount of money each week and invest a certain amount of - your psyche time - in which we would be working together.  A $4.00- $16.00 discount is offered to clients who prepay for their appointments or pay at the time of service.

In addition, clients contribute their readiness by attending every session. The frequency of visits differs from client to client, but most people start therapy by scheduling one session per week. It is also important to start and end each session on time. But most importantly, you need to bring a willingness to participate in your own healing fully. You may want to prepare for your appointment, in your mind, on your way to my office. Some clients find it helpful to keep a diary of thoughts and dreams as a way to review the past week to come every week and bring the parts of themselves’ that they are ready to share at that particular time.  The work you do in and between appointments is the other important part of your investment in psychotherapy.

For your New Client consultation and appointment please arrive 10-15 minutes before your appointment so you can complete the necessary paperwork. Arriving late will result in utilizing appointment time to complete the forms. You will be charged for this time as part of your first appointment, so you are encouraged to arrive early.

Please be sure to take a bathroom stop on your way into your appointment. Full bladders are uncomfortable and can be a distraction during your Hypnotherapy appointment.

*Upon entering the therapy room, I ask that you turn off anything that rings, beeps, buzzes, etc. You are expected to turn off all your gadgets and make necessary arrangements so you will not need to be disturbed during your appointment. It is recommended that you leave electronic equipment in your car. This will save you time and expense.

Payment is required at beginning of each appointment. Cash, personal check, Visa, Master Card, Discover, and American Express (accepted through PayPal) are accepted. I do not bill Insurance. For Credit Card payments go to http://www.therapiesforwellbeing.com/MakeaPayment.html, Click on the PayPal button. It will take you to the PayPal site. Enter the amount due for your appointment or your bill and follow the instructions. It’s fast and it’s easy. To receive the Discount, payment must be made by the time of service or within 24 hours of your appointment.

A $30.00 service charge will be assessed for returned checks.

Billing occurs around the 1st and 15th of every month. There is an $8.00 administrative fee charge for those who require billing. This charge is assessed per billing cycle. No discounts are applied for clients who require billing

Payments received more than thirty days after the date due are subject to 19.8 annual percentage service charge calculated on a monthly rate of 1.65% of the remaining balance. Delinquent bills will be turned over to a collection agency. The patient is responsible for the original bill, service charges, collection fees as well as any legal costs that are incurred as a result of the collection process.

 Appointment changes and cancellations require 48-hour notice. Missed or canceled appointments without prior 48-hour notice will be charged at the regular full rate ($108.00) to the client.

Appointments are scheduled for a particular time. If you are late, you will have the opportunity to receive the remaining time of your appointment.

Please sign this form, return one copy and keep a copy for yourself for future reference. Should you have any questions at any time, please ask.

Client Name (please print): ___________________________________________________________

Client or Guardian Signature: _________________________________________________________

Client Address _____________________________________________________________________

                        Street                           City                              State                                        Zip Code

Client Email Address: _______________________________________________________________

SSN: ___________________________________________DOB: ___________________ Age: _____

Phone: Day _________________________________ Evening ______________________________

Occupation: _______________________________________________________________________

How did you hear of this office: ________________________________________________________

Emergency Contact: __________________________________Phone: __________________________

Relationship To You: _______________________________________________________________

Therapist’s Signature _______________________________________________Date: ____________

Consent to Bi-Lateral Release of Information

 
Client: ­___________________________________________
Date of Birth: _____/_____/_____
 
I hereby request and authorize Rebecca Armstrong C.C.Ht. and _________________________________________________________________________
 
_________________________________________________________________________
to exchange information about me. Information may be exchanged with respect to any illness, medical history, consultation, evaluation, counseling/psychotherapy, school performance, drug or alcohol abuse, and behavior during the period from initial contact to the last date of contact.
 
I understand that I may request in writing that specific portions of my records not be released
or referred to in the course of taking action upon this request.                             ­
 
The following portion(s) of my record ___________________________________________________________
____________________________________________________________________ shall be released for the purpose of (please state exact purpose): _________________________________________________________
_________________________________________________________________________________________
 
I understand that I may refuse to consent to this release without penalty and I or without being refused services. I also understand that I may withdraw this consent at any time except to the extent that action has already been taken in reliance thereon. All blanks were filled in prior to my signing this consent.
Client Signature   _____________________________________________________Date _____/_____/_____

Parent/Guardian Signature if Client is a Minor _______________________________ Date _____/_____/____
Therapist Signature ___________________________________________________ Date _____/_____/_____