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Terms and Policy

INFORMED CONSENT
Welcome to my counseling and psychotherapy practice! 


I have a Master's degree in Social Work, which I received in 1986, and have been licensed as a Social Worker since 1988. I have been providing counseling, psychotherapy, assessment and evaluation services since that time. In addition, I am Department of Transportation qualified as a Substance Abuse Professional (SAP) to do evaluations related to substance use or testing positive for substance use while working in DOT safety sensitive positions. I have expertise in the treatment of alcohol and opioid use disorders and also medication assisted therapy for these disorders, having spend a decade working extensively with a psychiatrist who is Board Certified in Addiction. I also provide Eye Movement Desensitization and Reprocessing (EMDR) consultation and training to psychotherapy professionals. 

I provide individual, couples, family and group counseling and psychotherapy services within my practice. I meet with most patients on a weekly or bi-weekly basis. Initial sessions, couples and family sessions are frequently scheduled for 60 or 90 minutes. Phone or internet sessions are sometimes used as an adjunct to face to face counseling sessions, or in special circumstances when it is not possible to meet face to face. Group treatment sessions are generally 90 minutes long, and those meetings are typically weekly or bi-weekly. In the event that substance abuse is an issue I may order laboratory studies, including toxicology screens, to further evaluate this. If it is therapeutically appropriate I sometimes recommend that a patient use a breathalyzer device.

The primary types of therapy that I do are Cognitive Behavioral Therapy (CBT), and Eye Movement Desensitization and Reprocessing (EMDR). I also use Brainspotting, mindfulness and mindfulness meditation interventions, Energy Psychology Therapies, and integrate other types of therapies as seems clinically appropriate. 


Cognitive Behavioral Therapy (CBT) 

CBT is a psychotherapeutic approach that aims to solve or reduce problems concerning dysfunctional emotions, behaviors and cognitions. It is a solution-focused approach to therapy. CBT is an umbrella term for a number of psychological techniques that share a theoretical basis in behavioral learning theory and cognitive psychology. There is empirical evidence that CBT is effective for the treatment of a variety of problems, including mood, anxiety, personality, eating, substance abuse, and psychotic disorders. Mindfulness and mindfulness meditation focus on becoming aware of all incoming thoughts and feelings and accepting them, but not attaching or reacting to them. As a solution-focused therapist I work with my clients to identify what they would like to accomplish in therapy and together we identify strategies to help them to achieve those goals. As goals are achieved the patient may decide to end treatment, or may decide instead to continue working with me to address new goals as identified. Patents may decide to return at a later date to address new goals. Homework is frequently discussed and assigned as an adjunct to the work we do in sessions. In this way clients are able to practice new skills and behaviors which support identified goals. As an adjunct to the work that I do with patients I commonly suggest that they access and utilize resources outside of counseling sessions, such as books, articles, classes, support groups, and treatment groups. As a part of my practice I teach patients about strategies and techniques that, if used, may help them to achieve stated goals. We may also practice these strategies and techniques in counseling sessions. 


Eye Movement Desensitization and Reprocessing (EMDR Therapy)
- I am Level I and II trained, EMDRIA certified in Eye Movement Desensitization and Reprocessing (EMDR), and am an EMDRIA Approved EMDR Consultant. EMDR was developed by Francine Shapiro in 1987. EMDR was initially found to be effective to treat post-traumatic stress. This has been demonstrated empirically. EMDR may also be helpful in the treatment of panic attacks, complicated grief, dissociative disorders, disturbing memories, phobias, pain disorders, eating disorders, performance anxiety, stress reduction, addictions, sexual and/or physical abuse, body dysmorphic disorders and personality disorders, and to enhance performance and creativity and treatment for these issues is considered to be experimental. 

EMDR Therapy "is a psychotherapy that enables people to heal from the symptoms and emotional distress that are the result of disturbing life experiences.  Repeated studies show that by using EMDR therapy people can experience the benefits of psychotherapy that once took years to make a difference. It is widely assumed that severe emotional pain requires a long time to heal.  EMDR therapy shows that the mind can in fact heal from psychological trauma much as the body recovers from physical trauma.  When you cut your hand, your body works to close the wound.  If a foreign object or repeated injury irritates the wound, it festers and causes pain.  Once the block is removed, healing resumes.  EMDR therapy demonstrates that a similar sequence of events occurs with mental processes.  The brain's information processing system naturally moves toward mental health.  If the system is blocked or imbalanced by the impact of a disturbing event, the emotional wound festers and can cause intense suffering.  Once the block is removed, healing resumes.  Using the detailed protocols and procedures learned in EMDR therapy training sessions, clinicians help clients activate their natural healing processes. More than 30 positive controlled outcome studies have been done on EMDR therapy.  Some of the studies show that 84%-90% of single-trauma victims no longer have post-traumatic stress disorder after only three 90-minute sessions.  Another study, funded by the HMO Kaiser Permanente, found that 100% of the single-trauma victims and 77% of multiple trauma victims no longer were diagnosed with PTSD after only six 50-minute sessions. In another study, 77% of combat veterans were free of PTSD in 12 sessions. There has been so much research on EMDR therapy that it is now recognized as an effective form of treatment for trauma and other disturbing experiences by organizations such as the American Psychiatric Association, the World Health Organization and the Department of Defense. Given the worldwide recognition as an effective treatment of trauma, you can easily see how EMDR therapy would be effective in treating the "everyday" memories that are the reason people have low self-esteem, feelings of powerlessness, and all the myriad problems that bring them in for therapy. Over 100,000 clinicians throughout the world use the therapy.  Millions of people have been treated successfully over the past 25 years. EMDR therapy is an eight-phase treatment.  Eye movements (or other bilateral stimulation) are used during one part of the session.  After the clinician has determined which memory to target first, he asks the client to hold different aspects of that event or thought in mind and to use his eyes to track the therapist's hand as it moves back and forth across the client's field of vision.  As this happens, for reasons believed by a Harvard researcher to be connected with the biological mechanisms involved in Rapid Eye Movement (REM) sleep, internal associations arise and the clients begin to process the memory and disturbing feelings. In successful EMDR therapy, the meaning of painful events is transformed on an emotional level.  For instance, a rape victim shifts from feeling horror and self-disgust to holding the firm belief that, "I survived it and I am strong."  Unlike talk therapy, the insights clients gain in EMDR therapy result not so much from clinician interpretation, but from the client's own accelerated intellectual and emotional processes.  The net effect is that clients conclude EMDR therapy feeling empowered by the very experiences that once debased them.  Their wounds have not just closed, they have transformed. As a natural outcome of the EMDR therapeutic process, the clients' thoughts, feelings and behavior are all robust indicators of emotional health and resolution-all without speaking in detail or doing homework used in other therapies. Treatment Description: EMDR therapy combines different elements to maximize treatment effects.  A full description of the theory, sequence of treatment, and research on protocols and active mechanisms can be found in F. Shapiro (2001) Eye movement desensitization and reprocessing:  Basic principles, protocols and procedures (2nd edition) New York: Guilford Press. EMDR therapy involves attention to three time periods:  the past, present, and future.  Focus is given to past disturbing memories and related events.  Also, it is given to current situations that cause distress, and to developing the skills and attitudes needed for positive future actions.  With EMDR therapy, these items are addressed using an eight-phase treatment approach." (From EMDR Institute, Inc. description)

Brainpotting

I am Level I and II trained in Brainspotting (BSP), which was developed in 2003 by David Grand, PhD. It is believed that that BSP taps into and harnesses the body's natural self-scanning, self-healing ability. When a Brainspot is stimulated, the deep brain appears to reflexively signal the therapist that the source of the problem has been found. BSP can also be used to find and strengthen our natural resources and resilience. BSP is designed as a therapeutic tool that can be integrated into a many of healing modalities. BSP can also be used with performance and creativity enhancement. Brainspotting is considered to be an experimental treatment.

Heartmath

Heartmath is a tool that I often use to teach relaxation skills. I have installed a program on my laptop computer called Heartmath which allows my clients and me to monitor achievement with visual and auditory cues using a simple and non-invasive monitor, which is placed on a finger or on the earlobe. Research that indicates that when heart rhythm patterns are smooth and balanced people are less susceptible to sickness and disease, are more energetic, and are able to perform daily affairs more effectively and with greater clarity and ease.

Mindfulness and Meditation

I have received extensive training and a certification in mindfulness and medication as used in psychotherapy, and practice meditation myself. I integrate mindfulness and meditation practices into my work with patients. 

Empirically supported benefits of mindfulness

"The term "mindfulness" has been used to refer to a psychological state of awareness, the practices that promote this awareness, a mode of processing information and a character trait. To be consistent with most of the research reviewed in this article, we define mindfulness as a moment-to-moment awareness of one's experience without judgment. In this sense, mindfulness is a state and not a trait. While it might be promoted by certain practices or activities, such as meditation, it is not equivalent to or synonymous with them.

Several disciplines and practices can cultivate mindfulness, such as yoga, tai chi and qigong, but most of the literature has focused on mindfulness that is developed through mindfulness meditation - those self-regulation practices that focus on training attention and awareness in order to bring mental processes under greater voluntary control and thereby foster general mental well-being and development and/or specific capacities such as calmness, clarity and concentration (Walsh & Shapiro, 2006).

Researchers theorize that mindfulness meditation promotes metacognitive awareness, decreases rumination via disengagement from perseverative cognitive activities and enhances attentional capacities through gains in working memory. These cognitive gains, in turn, contribute to effective emotion-regulation strategies.

More specifically, research on mindfulness has identified these benefits:

Reduced rumination. Several studies have shown that mindfulness reduces rumination. In one study, for example, Chambers et al. (2008) asked 20 novice meditators to participate in a 10-day intensive mindfulness meditation retreat. After the retreat, the meditation group had significantly higher self-reported mindfulness and a decreased negative affect compared with a control group. They also experienced fewer depressive symptoms and less rumination. In addition, the meditators had significantly better working memory capacity and were better able to sustain attention during a performance task compared with the control group.

Stress reduction. Many studies show that practicing mindfulness reduces stress. In 2010, Hoffman et al. conducted a meta-analysis of 39 studies that explored the use of mindfulness-based stress reduction and mindfulness-based cognitive therapy. The researchers concluded that mindfulness-based therapy may be useful in altering affective and cognitive processes that underlie multiple clinical issues.

Those findings are consistent with evidence that mindfulness meditation increases positive affect and decreases anxiety and negative affect. In one study, participants randomly assigned to an eight-week mindfulness-based stress reduction group were compared with controls on self-reported measures of depression, anxiety and psychopathology, and on neural reactivity as measured by fMRI after watching sad films (Farb et al., 2010). The researchers found that the participants who experienced mindfulness-based stress reduction had significantly less anxiety, depression and somatic distress compared with the control group. In addition, the fMRI data indicated that the mindfulness group had less neural reactivity when they were exposed to the films than the control group, and they displayed distinctly different neural responses while watching the films than they did before their mindfulness training. These findings suggest that mindfulness meditation shifts people's ability to use emotion regulation strategies in a way that enables them to experience emotion selectively, and that the emotions they experience may be processed differently in the brain (Farb et al., 2010; Williams, 2010).

Boosts to working memory. Improvements to working memory appear to be another benefit of mindfulness, research finds. A 2010 study by Jha et al., for example, documented the benefits of mindfulness meditation among a military group who participated in an eight-week mindfulness training, a nonmeditating military group and a group of nonmeditating civilians. Both military groups were in a highly stressful period before deployment. The researchers found that the nonmeditating military group had decreased working memory capacity over time, whereas working memory capacity among nonmeditating civilians was stable across time. Within the meditating military group, however, working memory capacity increased with meditation practice. In addition, meditation practice was directly related to self-reported positive affect and inversely related to self-reported negative affect.

Focus. Another study examined how mindfulness meditation affected participants' ability to focus attention and suppress distracting information. The researchers compared a group of experienced mindfulness meditators with a control group that had no meditation experience. They found that the meditation group had significantly better performance on all measures of attention and had higher self-reported mindfulness. Mindfulness meditation practice and self-reported mindfulness were correlated directly with cognitive flexibility and attentional functioning (Moore and Malinowski, 2009).

Less emotional reactivity. Research also supports the notion that mindfulness meditation decreases emotional reactivity. In a study of people who had anywhere from one month to 29 years of mindfulness meditation practice, researchers found that mindfulness meditation practice helped people disengage from emotionally upsetting pictures and enabled them to focus better on a cognitive task as compared with people who saw the pictures but did not meditate (Ortner et al., 2007).

More cognitive flexibility. Another line of research suggests that in addition to helping people become less reactive, mindfulness meditation may also give them greater cognitive flexibility. One study found that people who practice mindfulness meditation appear to develop the skill of self-observation, which neurologically disengages the automatic pathways that were created by prior learning and enables present-moment input to be integrated in a new way (Siegel, 2007a). Meditation also activates the brain region associated with more adaptive responses to stressful or negative situations (Cahn & Polich, 2006; Davidson et al., 2003). Activation of this region corresponds with faster recovery to baseline after being negatively provoked (Davidson, 2000; Davidson, Jackson, & Kalin, 2000).

Relationship satisfaction. Several studies find that a person's ability to be mindful can help predict relationship satisfaction - the ability to respond well to relationship stress and the skill in communicating one's emotions to a partner. Empirical evidence suggests that mindfulness protects against the emotionally stressful effects of relationship conflict (Barnes et al., 2007), is positively associated with the ability to express oneself in various social situations (Dekeyser el al., 2008) and predicts relationship satisfaction (Barnes et al., 2007; Wachs & Cordova, 2007).

Other benefits. Mindfulness has been shown to enhance self-insight, morality, intuition and fear modulation, all functions associated with the brain's middle prefrontal lobe area. Evidence also suggests that mindfulness meditation has numerous health benefits, including increased immune functioning (Davidson et al., 2003; see Grossman, Niemann, Schmidt, & Walach, 2004 for a review of physical health benefits), improvement to well-being (Carmody & Baer, 2008) and reduction in psychological distress (Coffey & Hartman, 2008; Ostafin et al., 2006). In addition, mindfulness meditation practice appears to increase information processing speed (Moore & Malinowski, 2009), as well as decrease task effort and having thoughts that are unrelated to the task at hand (Lutz et al., 2009)." (American Psychological Association (APA) Monitor on Psychology, July/August 2012,"What are the Benefits of Mindfulness").


Energy Psychology

"Energy psychology (EP) is a collection of mind-body approaches for understanding and improving human functioning. EP focuses on the relationship between thoughts, emotions, sensations, and behaviors, and known bioenergy systems (such as meridians and the biofield). These systems and processes exist, and interact, within individuals and between people. They are also influenced by cultural and environmental factors.

Within an EP framework, emotional and physical issues are seen, and treated, as bio-energetic patterns within a mind-body-energy system. The mind and body are thought to be interwoven and interactive within this mind-body-energy system, which involves complex communication involving neurobiological processes, innate electrophysiology, psychoneuroimmunology (PNI), consciousness, and cognitive-behavioral-emotional patterns.

The use of EP has resulted in the development of associated methods and models to treat psychological and emotional problems, facilitate health and wellbeing, and improve human performance. These models and methods are usually used within an integrative or holistic approach to practices such as psychotherapy, counseling, coaching, integrative medicine, and other healing modalities.EP models have been beneficially applied to assessment and treatment of trauma, anxiety, depression, pain, stress, psychophysiological issues, and self-sabotaging behaviors by a broad range of healthcare providers, to regulate affect and promote emotional and physical health. Treatment results have been shown to be enduring and relatively rapid. There are currently over 100 research studies, including 50 randomized controlled trials (RCT) published in professional and refereed journals, confirming the treatment value of EP. Taken as a body of knowledge, these findings suggest that EP meets the criteria for evidenced-based treatment. In fact, in 2016, TFT (Thought Field Therapy) was validated by NREPP (the National Repertory of Evidence Based Practices and Procedures, a division of SAMHSA in the U.S.) as an evidence-based treatment." (From Association for Comprehensive Energy Psychology (ACEP))


RISKS AND BENEFITS OF THERAPY

Psychotherapy can have both benefits and risks. Psychotherapy has been shown to have benefits for people who go through it. Therapy can lead to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There is evidence that some types of psychotherapy offer equal or better treatment results at a lower cost than medication.

However, since therapy often involves discussing unpleasant aspects of your life, patients may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Approaching feelings or thoughts that you have tried not to think about for a long time may be painful. Processing emotionally traumatic events may initially increase discomfort. Making changes in your beliefs or behavior can be scary, and sometimes disruptive to the relationships. It is important that you consider carefully whether these risks are worth the benefits to you of changing.


CONFIDENTIALITY AND THE LIMITS OF CONFIDENTIALITY

The information you discuss during a psychotherapy session is protected as confidential under law (C.R.S. 12-43-214)(1)(d)) with certain limitations.

- It is my policy and responsibility to report suspected child abuse and elder abuse, without an investigation, to the proper authorities, who may then investigate.
- I may also take some action, such as seek an order for your emergency or involuntary commitment under C.R.S. 27-10-101, without your consent if I feel that you are either gravely disabled or I deem you to be a serious harm to yourself or to another. Any action I take without your consent will be discussed with you if possible.
- If I am unable to collect the agreed upon fee, I may send your name to a collection agency.
- According to Colorado Law, your right to confidentiality is waived in the event that you file an official complaint or a lawsuit against me.
- If you chose to use your health benefit plan, you will have given your insurance or managed care company consent to obtain required confidential information for the purpose of determining eligibility for reimbursement. (See Health Care Benefits.)
- I sometimes consult with other therapists or other professionals about my patients. This helps me to provide quality treatment. However, these persons are required to keep your information private. And, in order to protect your personal information and identity, your name will never be given to them, some information will be changed or omitted, and they will be told only as much as I believe that they need to know in order to understand your situation.
- Clerical, billing, and other persons hired by me may have access to limited confidential information. This information is protected from further disclosure and is used solely for administrative purposes.
- When I am away from my office for a few days, I may ask another licensed therapist to cover emergences for me. Generally, I will tell this therapist only what he or she needs to know for an emergency.


CONFIDENTIALITY AND TECHNOLOGY EMAILS, TEXT MESSAGING, VOICE MESSAGES, FAXES, PHONE, INTERNET:
When working with patients I prefer using email or text messaging only in cases when a client wishes to arrange or modify appointments. Please do not email me content related to your therapy sessions, as email is not completely secure or confidential. If you choose to communicate with me by email, be aware that all emails are retained in the logs of your and my Internet service providers. These transmissions may be accessible to others, such as system administrators or the Internet service providers, employers, or government agencies. In addition, I may not have access to emails or text messages, or I may not receive an email, voicemail or fax due to a technology failure. In addition, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). Adding clients as friends or contacts on these sites can compromise confidentiality and privacy and may also blur the boundaries of our therapeutic relationship. Many clients choose to use cell phones, cordless phones, faxes, email, video-conferencing and computers to augment their counseling with me. These methods of communication may not be completely secure despite best efforts.

HEALTH CARE BENEFITS
If you choose to use your health care benefits, and my services are reimbursable under your insurance plan, you must give me written authorization to release required information. Released confidential information may range from identifying information, diagnosis, dates and types of sessions and charges to a complete assessment with treatment goals and progress reports when your benefits fall under managed care. My policy is to provide only the least amount of information necessary for the purpose of authorizing benefits. However, it is necessary that I provide insurers and often employee assistance programs with a diagnosis and other personal information. I cannot be in control of the storage of confidential information nor access to your confidential information when it is given to a third party. The insurance company will determine benefit coverage and the kind of service for which they will reimburse. I will discuss with you my recommendation for treatment and you will decide how you want to proceed. You are responsible for seeing that my services are paid for regardless of whether the insurance company will reimburse for treatment you receive. Many people choose to self-pay for psychotherapy services in order to better safeguard their privacy.


AVAILABILITY
You may leave a voicemail message 24 hours a day and I will attempt to return your call within 24 hours during the weekdays or on the first working day following a weekend or holiday. I will get back to you as soon as is possible. It is my policy to charge for calls such as these at my regular rate in 15-minute increments. Please call 911 or go to the nearest emergency room if there is a life-threatening emergency. If I am away for an extended time and unable to respond to calls I ask another licensed therapist to manage urgent calls for me.


GRIEVANCE PROCEDURE
If you are unhappy with the services you receive from me you it is important that you indicate that to me either in writing, by phone, or in person. In addition, the practice of both licensed and unlicensed psychotherapists is regulated by the Department of Regulatory Agencies under CRS 12.43.214 (1)(c) . Under this statute, 12.43.214(1)(d)CRS, you are entitled to receive information about the methods of therapy, the techniques used, the duration of therapy (if known), and the fee structure. You may seek a second opinion from another therapist or may terminate therapy at any time. In a professional relationship, sexual intimacy is inappropriate and intolerable and should be reported to the Grievance Board.


ACCESS TO RECORDS
Patient records are kept and stored securely and in a manner that both assures that only authorized persons have access to records and protects the confidentiality of the records and of the information contained in the records. Records are kept for 7 years as required by Colorado Statute. Patients are granted reasonable access to their records, but not my psychotherapy notes. You may request, in writing, an amendment to your record. If you choose to read your record, it is my policy to be present in order to respond to any questions or confusion you have about the recordings.


LENGTH OF TREATMENT
I generally meet with patients once weekly or, after the first several sessions, biweekly, for four to six months. There are times I meet with clients for an agreed upon finite number of sessions (as in the case of a consultation, an evaluation, or employee assistance services). Sessions are generally 45-minutes in duration, and  intake appointments are typically 60 minutes to 90 minutes in duration. Sessions may be extended when there is a clinical need. During the course of treatment we generally review progress and goals often. As treatment progresses and goals are met we generally decrease the frequency of sessions. As we approach termination we will review our goals and what has been accomplished, discuss strategies for future success, and identify additional goals for the future. Sometimes patients choose to take a break from counseling and then resume sessions at a later time to continue to work on achieving goals, or we end treatment and they choose to return for a brief number of sessions during periods of stress for support, to review strategies, or to address other issues that have arisen in the interim.

TERMINATION
Termination will usually be agreed upon mutually, but you are free to terminate treatment at any time. Unless we have made other arrangements, I will assume that you have terminated treatment if you have not scheduled with me for a period of one month or more. 


I reserve the right to terminate our relationship for any reason, including but not limited to whenever, in my opinion, an effective therapeutic relationship cannot be established or maintained. I may also terminate our relationship is you have failed to meet the terms of our fee agreement, or if I determine that there is a need for special services outside of my area of competency, or if there is prolonged failure to make progress in our work together.  Should this occur, you will be notified of the reason for termination and, if you would like, I will help you to make different plans for yourself such as a referral to a more appropriate treatment resource.

ACKNOWLEDGEMENT OF INFORMED CONSENT

I have read the preceding information, it has also been provided verbally, and I have asked any questions I have. I fully understand the treatment considerations and risks presented in this form.

( Type Full Name )
( Full Name )
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information ("PHI"). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act ("HIPAA"), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.

Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

Without Authorization. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.

As a social worker licensed in this state and as a member of the National Association of Social Workers, it is our practice to adhere to more stringent privacy requirements for disclosures without an authorization. The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPAA.

Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.

Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.

Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person's estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.

Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

Family Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

Health Oversight. If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.

Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.

Specialized Government Functions. We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.

Public Health. If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Research. PHI may only be disclosed after a special approval process or with your authorization.

Fundraising. We may send you fundraising communications at one time or another. You have the right to opt out of such fundraising communications with each solicitation you receive.

Verbal Permission. We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer at 7400 West 14th Avenue, Suite #6, Lakewood, Colorado 80214:

- Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a "designated record set". A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.

- Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.

- Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.

- Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.

- Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.

- Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.

- Right to a Copy of this Notice. You have the right to a copy of this notice.

COMPLAINTS

If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer at 777 South Wadsworth Boulevard, Building 1 Suite 201, Lakewood, Colorado 80226, or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.

The effective date of this Notice is September 2013.
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( Full Name )
DISCLOSURE STATEMENT
1. Jenny Bridges, LCSW
777 South Wadsworth Boulevard

Building 1, Suite 201

Lakewood, Colorado 80226
720-350-1109

2. DEGREES AND CREDENTIALS

- Master of Arts in Social Work, University of Denver, 1986
(Requirements: This degree required completion of Bachelor of Arts in Social Work from an accredited program, four quarters of classroom instruction, and completion of a supervised internship)
- Bachelor of Arts in Social Work, Colorado State University, 1982
(Requirements: This is a four-year degree which also required completion of a supervised field placement)
- Licensed Clinical Social Worker, State of Colorado # 989009
(Requirements: Master's degree in social work from a CSWE approved program, passage of the Advanced Generalist or Clinical level ASWB exam, completion of two years, 3360 hours post degree supervised experience with at least 96 hours of supervision, 48 hours of which must be individual supervision, and completion of continuing competency requirements)
- Academy of Certified Social Workers #881510255
(Requirements: Work experience totaling at least 3000 hours or two years of full-time employment within no less than 24 months, three professional references, two years of social work supervision by an MSW after receiving master's degree)
- Certified Therapist in EMDR
(Requirements: Completion of weekend 1 and 2 Trainings, reading of textbook EMDR Basic Principles, Protocols and Procedures (Shapiro, 2001), 10 hours of case consultation with EMDR Institute Approved Consultant, Completion of Level I and II EMDRIA approved training, licensed as a mental health professional, minimum two years of experience in licensure area, minimum 50 EMDR sessions with minimum 25 clients, 20 hours of consultation by an Approved Consultant in EMDR after completion of EMDRIA Approved Basic Training, letters of recommendation from one or more Approved Consultants in EMDR, two letters of recommendation from colleagues or peers, 12 hours of EMDRIA continuing education in EMDR)
-Approved Consultant in EMDR
(Requirements: EMDR Certification, a minimum of three years of experience with EMDR after completing an EMDRIA Approved Training Program, have conducted at least three hundred clinical sessions in which EMDR was utilized, have received twenty hours of consultation-of-consultation from an EMDRIA Approved Consultant, and have at least twelve hours of continuing education in EMDR every two years.)
- Colorado Approved Problem Gambling Counselor (Approval, not Certification)
(Requirements: 12 hours of consultation with an Approved Problem Gambling Consultant, 20 hours working with problem gambling, eight of which must be face-to-face with a problem gambler or family member; the remaining 12 must be problem gambling related, completion of 30 hours of problem gambling training, taking and passing the exam with a score of at least 80%)
- Qualified Substance Abuse Professional (Qualification, not Certification)
(Requirements: Completion of training specific to SAP duties and DOT rules, successful completion of an examination covering this training, documentation of trainings, completion of 12 hours of continuing education to update SAPS on changes and developments in the DOT drug and alcohol testing program every 3 years)
- Institute for Meditation and Psychotherapy Certificate of Training
(Requirements: Completion of 60 continuing education credits including education, retreat experience, and consultation specific to mindfulness and meditation in psychotherapy practice. 09-13-2012 to 06-16-2013)

3. 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 Social Work Examiners can be reached at: 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.

4. As to the regulatory requirements applicable to mental health professionals: 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-doctoral supervision. A Licensed Social Worker must hold a masters 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 1,000 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 bachelors 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 masters degree and meet the CAC III requirements. A Registered Psychotherapist is registered with the State Board of Registered Psychotherapists, is not licensed or certified, and no degree, training or experience is required.

5. You are entitled, to receive information from your therapist about the methods of therapy, the techniques used, the duration of your therapy, if known, and the fee structure. You can seek a second opinion from another therapist or terminate therapy at any time.

6. In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant or certificate holder.

7. Generally speaking, the information provided by and to the client during therapy sessions is legally confidential and cannot be released without the client's consent. There are exceptions to this confidentiality, some of which are listed in section 12-43-218 [If you are HIPAA covered add: "and the Notice of Privacy Rights you were provided"] as well as other exceptions in Colorado and Federal law. For example, mental health professionals are required to report child abuse to authorities. If a legal exception arises during therapy, if feasible, you will be informed accordingly.

I have read the preceding information, it has also been provided verbally, and I understand my rights as a client or as the client's responsible party.

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( Full Name )