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Terms and Policy

What Clients Should Know About the Relationship With Their Therapist
The relationship between therapist and client is a unique one. Psychotherapy is a professional service provided, and because of that the relationship between you as the client and myself as the therapist has limitations and safeguards. For instance, as your therapist, I cannot have a business relationship with you besides the therapy itself, I cannot have a social relationship with you, I cannot be your friend. If we were to interact in ways such as these, we would then have a “dual relationship” which is neither right or legal. In addition to this, as your therapist I am required to keep the identity of my clients confidential. Therefore, It may appear that I ignore you when we meet in a public place. These limitations and safeguards exist to set the therapeutic process up for success, and honor you as the client.
( Type Full Name )
DISCLOSURE STATEMENT
CREDENTIALS:

Licensure: LMFT, CACII

Degrees: My highest earned degree is a Master of Science from the University Colorado Boulder in Museum and Field Studies with a concentration in Anthropology. I have also earned a Bachelor of Science from Nazareth College of Rochester in Studio Art, and the equivalent of a Bachelor of Art in Art Education from Nazareth College of Rochester. I have completed extensive Post-graduate training in Psychotherapy at the Colorado School for Family Therapy.

Certifications: Greg Kersten's OK Corral Series Certification in Equine Assisted Psychotherapy, 2018 - 24 hours of training. Board Certified Professional Christian Counselor through the Board of Christian and Professional Pastoral Counselors, 2017 - 60 hours of training. Certified EFT Therapist through the International Center for Excellence in Emotionally Focused Therapy, 2016 - 98 hours of training, Certified Splankna (CSP) through the Splankna Therapy Institute, 2015 - 78 hours of training. Certified Brainspotting Practitioner through David Grand, Ph.D, 2014 - 95 hours of training. I have earned the following certifications through The Colorado School for Family Therapy board of Directors: Certified Systemic Art Therapist (CSAT), 2011-30 hours of training, Certified Systemic Play Therapist (CSPT), 2011-30 hours of training, Certified Body Centered Psychotherapist (CBCP), 2011-45 hours of training, Certified Trauma & Abuse Psychotherapist (CTAP), 2012-45 hours of training, and Certified Trauma Informed Systemic Psychotherapist (CTISP), 2012-45 hours of training.  

Professional Experience: I have been in private practice for individuals, couples, families, children, and groups since April 2011. My theoretical orientation is Integrative (Client centered, Body -Centered, Psychoeducational, and Systemic).  

Professional Associations: I am a member of the following Associations:

       American Association of Marriage and Family Therapy

       Rocky Mountain Brainspotting Institute

       International Centre for Excellence in Emotionally Focused Therapy

       Boulder Center for Emotionally Focused Therapy

       International Association of Trauma Professionals

       Colorado Association of Addiction Professionals

       American Association of Christian Counselors

REGULATION OF PSYCHOTHERAPISTS

The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The Board of Marriage and Family Therapists can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.

The regulatory requirements for mental health professionals provide that a 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-doctorial supervision. A Licensed Social Worker must hold a master's degree in social work.

A 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. A Certified Addiction Counselor I (CAC I) must be a high school graduate, and complete required training hours and 1000 hours of supervised experience. A CAC II must complete additional required training hours and 2,000 hours of supervised experience. A CAC III must have a bachelor's degree in behavioral health, and complete additional required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical master's degree and meet the CAC III requirements. A Registered Psychotherapist is listed in the State's Database and is authorized by law to practice psychotherapy in Colorado, but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state. 

CLIENT RIGHTS AND IMPORTANT INFORMATION

       You are entitled to receive information from me about my methods of psychotherapy, the techniques I use, the fee structure, and the duration of your therapy (if I can determine it). Please ask if you would like to receive this information.

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

       In a professional relationship (such as ours), sexual intimacy is never appropriate. If sexual intimacy occurs, it should be reported to the board that licenses, certifies or registers the therapist.

       Generally speaking, information provided by and to a client in a professional relationship with a psychotherapist is legally confidential, and the therapist cannot disclose the information without the client's consent. There are several exceptions to confidentiality which include: (1) I am required to report any suspected incident of elder abuse or neglect and child abuse or neglect to law enforcement;  child abuse or neglect shall immediately, upon receiving such information, be reported to the county department, the local law enforcement agency, or through the child abuse reporting hotline system. (2) I am required to report any threat of imminent physical harm by a client to law enforcement and to the person(s) threatened; (3) I am required to initiate a mental health evaluation of a client who is imminently dangerous to self or to others, or who is gravely disabled, as a result of a mental disorder; (4) I am required to report any suspected threat to national security to federal officials; (5) I am required to report abuse of a senior, who is 70 years of age or older, which I believe has probably occurred, including institutional neglect, physical injury, financial exploitation, or unreasonable restraint; and (6) I may be required by Court Order to disclose treatment information.

       If you are 18 years or older and disclose to me that you were abused as a minor I do not have a duty to report except if there is reasonable cause to know or suspect that the perpetrator has subjected another child currently under 18 to abuse or neglect or to circumstances that would likely result in abuse or neglect or if the perpetrator is currently in a position of trust as defined in C.R.S 18-3-4-1 (3.5) with regard to any child currently under 18.

       When I am concerned about a client's safety, it is my policy to request a Welfare Check through local law enforcement. In doing so, I may disclose to law enforcement officers information concerning my concerns. By signing this Disclosure Statement and agreeing to treat with me, you consent to this practice, if it should become necessary.

       Under Colorado law, C.R.S.  14-10-123.8, parents have the right to access mental health treatment information concerning their minor children, unless the court has restricted access to such information. Feel free to ask me treatment questions at any time. If you request written treatment information from me, I will provide you with a treatment summary, in compliance with Colorado law and HIPAA Standards.

       I agree not to record our sessions without your written consent; and you agree not to tape record a session or conversation with me without my written consent.    
                                                                                                                                                

AS A PSYCHOTHERAPY CLIENT

       I understand my psychotherapist provides non-emergency psychotherapeutic services by scheduled appointment only. If, for any reason, I am unable to contact my psychotherapist by telephone, (303) 521-0653 and I am having a true mental health emergency, I will either call 911, call Colorado Crisis Services (844) 493-8255, or check myself into the nearest hospital emergency room.      

       If at any time my psychotherapist believes my psychotherapeutic issues are above her level of competence, or outside of her scope of practice, she is legally required to refer, terminate, or consult. 

       I understand that there may be times when my psychotherapist may consult with colleague or another professional, like an attorney, about issues raised by me in therapy.  My confidentiality is still protected during consultation by my psychotherapist and the professional consulted.  Signing this disclosure statement gives my psychotherapist permission to consult as needed to provide professional services to me as a client.

       I agree to inform my psychotherapist of any change in my contact information such as changes in address or phone number or emergency contact information within one week of when the changes arise.

       I understand that when I wish to terminate therapy it is advisable to schedule a final appointment with my psychotherapist to review the progress made and to confirm future strategies. In the event that I do not participate in a final appointment. If for some reason I do not return to therapy and do not inform my therapist that I will not be returning at this time within 30 days from my last visit, my therapist will consider my current case closed. I am always welcome to return to therapy at any time. 

      My records regarding the treatment of adults will be kept for (7) years after treatment ends or following our last session, but may not be kept after seven years. My records for treatment of minors will be kept for seven (7) years, commencing on the last date of treatment or when a minor reaches 18 years of age, whichever comes later, but in no event am I required to keep these records for longer than 12 years.

Marriage and Family Therapy

       I understand that in marriage and family counseling, my therapist holds a "NO SECRETS" policy.  All members of the couple or family system are treated equally and "secrets" are not kept by the therapist that require differential or discriminatory treatment of family members. I understand that any information shared in individual therapy MUST be also shared in couple or family therapy to insure this "NO SECRETS" policy. Signing this disclosure statement affirms permission to share this confidential information.

       Disclosure Regarding Divorce and Custody Litigation

       If you are involved in divorce or custody litigation, or become involved in a divorce or custody litigation my role remains as your therapist. Therefore, I do not make recommendations to the court concerning custody or parenting issues. By signing this Disclosure Statement, you agree not to subpoena me to court for testimony or for disclosure of treatment information in such litigation; and you agree not to request that I write any reports to the court or to your attorney, making recommendations concerning custody.  The court can appoint professionals, who have no prior relationship with family members, to conduct an investigation or evaluation and to make recommendations to the court concerning parental responsibilities or parenting time in the best interests of the family's children.                                                                                  

FEES AND CLIENT RESPONSIBILITY:

My fee for psychotherapy services ranges from $135.00-$125.00 per 55-60 minute session. A reduced rate of $90.00 per 60 minute session is available for military. Sessions may be continued beyond the 60 minute hour (at the same hourly rate billed in 15 minute increments) at the request of the patient and the discretion and availability of the therapist. Telephone calls over 10 minutes in length will be billed at the same rate.

Payment is required at the beginning of each session. I prefer cash or check. I can take HSA cards as credit cards. In the event that my therapist bills my insurance, I understand that I am legally responsible for payment for psychotherapy services, if, for any reason, my third-party payor, (insurance company) etc. does not compensate my therapist. I also understand that signing this form gives permission to my psychotherapist to communicate with her billing service and my third-party payer or anyone connected to my psychotherapy funding source.

       If you do not complete payment on the unpaid balance of your account within a reasonable period of time (i.e. 30 days) and have not arranged a payment plan with me, please know that the account may be referred to a professional collection agency.  That agency may require that I release identifying information such as your name, address and dates of service.

       If you ask me to provide other services such as report writing, telephone conversations lasting longer than 10 minutes, preparation of records or treatment summaries, consultations with other care providers, I will charge my regular $125 hourly fee.

       I understand that my psychotherapist requests at least 8 hours notice for cancellation of an appointment and I agree to give my therapist this courtesy via text, phone call or email.

       I understand that if I miss an appointment without informing my psychotherapist, I will be required to pay $50.00 for the inconvenience of the missed session. I agree to pay such fees within 30 days in the event that I neglect to show up for an appointment without contacting my psychotherapist before the scheduled appointment begins.

       I understand that if I am more than 15 minutes late for an appointment without notifying my therapist, she will consider this a missed appointment without notification and I will be required to pay $50.00 for the inconvenience.

       I understand that if I am late for a session, the session will still end at the scheduled time and I will be billed in full. I agree to pay the full fee in the event that I arrive late to the appointment.                                 

CLIENT SIGNATURE, ACKNOWLEDGEMENT, AGREEMENT, AND CONSENT

I have read the preceding information and it has also been provided verbally. I also affirm, by signing this form, that I am the legal guardian and/or custodial parent with legal right to consent to treatment for any minor child or children. I understand my rights as a client or as the client's responsible party. 

By signing below I acknowledge my understanding and agree to all the terms discussed in this disclosure statement.  By signing this disclosure statement, I also agree to permit consultation and I provide release for my therapist to seek consultation with other psychotherapists, professionals such as attorneys, or insurance companies as the need arises.  I am requesting psychotherapy services from Julie Marino and consent to treatment.

( Type Full Name )
Your Information. Your Rights. Our Responsibilities. (HIPAA)
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds

Our Uses and Disclosures
We may use and share your information as we:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record
• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.

Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures
How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.

Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research
We can use or share your information for health research.

Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Effective date: December 1, 2013

This notice of Privacy Practices applies to the following organizations:

Heart Therapy Counseling Services
Insurance Companies and Heart Therapy Counseling Services’ Insurance Billing Company
This authorization is prepared pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations as amended from time to time. You may refuse to sign this authorization.

By my signature below, I acknowledge that I have received and read the Notice of Health Information Privacy Practices. I have been provided a copy of, read and understand Heart Therapy Counseling Services HIPAA Privacy Notice containing a complete description of my rights, and the permitted uses and disclosures of my protected health information under HIPAA. Further, I acknowledge that any information used or disclosed pursuant to this authorization could be at risk for re-disclosure by the recipient and is no longer protected under HIPAA.
( Type Full Name )