Jenny telo Counseling Services tLLC - PDF document

1 Jenny telo Counseling Services, tLLC
Jenny telo Counseling Services, tLLC 2/16 Jenny Pelo Counseling Services, P LLC COUNSELING INFORMATION, DISCLOSURE OF CLIENT RIGHTS, AND CONSENT TO TREATMENT YOUR COUNSELOR Jenny Pelo MA, LPC, NCC EVALUATION AND INTAKE Effective psychotherapy is founded on mutual understanding and good rapport between client and ther apist. You will be interviewed to evaluate your needs and to determine the desirability of beginning counseling at Jenny Pelo Counseling Services, PLLC . If you and the therapist agree that the therap ist can meet your therapeutic needs, a plan of treatment will be developed. If the decision is made that other services would be more appropriate, your therapist will provide you with referrals that may better fit your needs. RIGHTS OF CLIENTS The Colorado Department of Regulatory Agencies (DORA) which regulates the practice of licensed and unlicensed individuals who practice psychotherapy, requires that the following information be given to psychotherapy clients. A client is entitled to receive inf ormation from the therapist about degrees and credentials, methods of therapy, techniques used, the possible duration of therapy, and the fee structure. You may seek a second opinion from another therapist or terminate therapy at any time. In a professiona l relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant or certificate holder. Information about your ri ghts regarding confidentiality is detailed below. The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Section of the Division of Registrations. The Regulatory Board can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202 or by phone at 303 - 894 - 7800. As to the regulatory requirements applicable to mental health professionals : A Licensed Professional Counselor must hold a master’s degree in their profession and have two years of post - master’s supervision. THERAPEUTIC PRACTICES Jenny Pelo Counseling Services, PLLC ’ s methods of treatment are based on standard psychological practices and techniques enhanced by the counselor’s emphasis on the integration of mind, body, spirit and community . These methods are utilized in conjunction with the client’s values and belief systems, including the client’s religious or spiritual perspective. Specific information regarding your therapist is found in the Staff Description you will be given in the initial session. FEES & PAYMENT: Our fees are stated in the insurance information and fee agreement form (s) which you will complete with your counselor in the initial interview. Fees are based on the standard therapeutic hour, which is a 6 0 - minute session. Fees are due in full at each s ession. Telephone conversations, r eading e - mail communication from you and responding, consulting with physicians, time involved in discussing your case, letters or summaries related to your therapy, and filling out any reports, may all be charged as regul ar sessions. INSURANCE You are responsible for determining if your health insurance cov ers psychotherapy through Jenny Pelo Counseling Services, PLLC . If your mental health benefit is accessed throu gh a managed care agency, Jenny Pelo Counseling Services, PLLC will file your claims. If you have regular indemnity insurance, you may choose to file your claims or h ave Jenny Pelo Counseling Services, PLLC file the claims for you. Jenny Pelo Counseling Services, LLC does not guarantee Jenny telo Counseling Services, tLLC 2/16 that your insurance compan y will pay your cl

2 aim. You are responsible for your accoun
aim. You are responsible for your account balance. APPOINTMENTS AND CANCELLATIONS All appointments are made directly with your counselor. This time is reserved for you, therefore if you are unable to keep a scheduled appointment, please notify your counselor at least 24 hours in advance. All clients will be charged their agreed upon fee for cancellations made with less than 24 hours ’ notice or for fai lure to show for an appointment u nless otherwise prohibited b y insurance company regulations. Note: This charge is not covered by insurance. Unforeseen emergency situations will be taken into account. CONFIDENTIALITY Information you provide during counseling is legally confidential. T here are exceptions to this confidentiality, some of which are listed in section 12 - 43 - 218 of the Colorado Re vised Statutes and in the Jenny Pelo Counseling Services, PLLC Notice of Privacy Practices. Information may not be released to individua ls or agenc ies outside of Jenny Pelo Counseling Services, PLLC without your signed authorization, except in those legal situations as noted. For example, therapists are required by law to report suspected child /elder abuse or neglect and the threat of harm to others . Additional issues regarding potential sharing of confidential information are presented in detail in the Notice of Jenny Pelo Counseling Services, PLLC Privacy Practices, a copy of which you will receive at your initial session. MAINTENANCE OF CLIENT RECORDS As a client, you may request a copy of your Client Re cord at any time. In accordance with the Rules and Regulations of the State Board of Licensed Professional Counselors, I wi l l maintain your client re cord (consisting of di sclosure statement, contact information, reasons for therapy, note s, etc.) for a period of seven (7) years after the termination of therapy or the date of our last contact, wh ichever is later. I cannot g uarantee a copy of your Client Record will exist after this seven - year period. EMERGENCIES Jenny Pelo Cou n s eling Services, PLLC does no t provide “emergency services”. For life threatening situations, please call 911 or go to your nearest emergency room . For non - life t hreatening situations you may call your counselor or you can cal l Colorado Crisis Services 1 - 844 - 493 - 8255. TERMINATION AND EVALUATION Although you may e nd treatment at any time, Jenny Pelo Counseling Services, PLLC prefers that you have at least one face - to - face termination session with your counselor rather than terminating by phone, mail, or dropping out of treatment wit hout notice. This final session allows time to c los e the therapeutic process. GENERAL CONSENT TO COUNSELING I consent to begin counseling, including evaluation, treatment, or referral. I agree to pay for counseling services, includin g medical, psychologic al or psychiatric consultation fees and testing charges. I have read the preceding information, and it has also been provided verbally, and I understand my rights as a client. I have been informed, in writing, of my counselor’s degree(s), credentials and l icense(s). Additionally, I have been given a copy of the supplemental document, Notice of Jenny Pelo Counseling Services’ Privacy Practices , and understand it to be incorporated as part of this disclosure and consent. A copy of this document has been given to me for my records as requested . Name of Client_ _______________________________________ Signature_________ __________________________ Name Parent /guardian for a minor_________________________ S ignature___________________________________ Counselor Signature________________________________________________ Date___________________