Suzanne Simon MA, NCC
                                                                      A Children’s Counseling Center
                                                                               4251 Date Street
                                                                   Colorado Springs, Colorado 80917
                                                                                719-243-1960

                                                                          DISCLOSURE STATEMENT

I am pleased you have chosen me as your counselor. Below you will find some helpful information. Please read carefully and sign in the provided space.
Qualifications:
B.S. University of Colorado, Boulder- Psychology
Certified Elementary School Teacher, University of Missouri- Elementary Education
M.A., University of Colorado, Colorado Springs- Clinical Mental Health Counseling
Nationally Certified Counselor
Registered Psychotherapist, Colorado
Nature of Counseling:
I am committed to providing the highest quality of services to my clients. I will give you all of the necessary information so that you will be informed regarding the treatment process. Please read the following paragraphs carefully. They will give you information regarding your rights as a client of mine as well as inform you of any ethical and financial issues. If you have any questions, please discuss them with me before signing this form.
You always have the right to seek a second opinion from another therapist and terminate at any time.
Our relationship is a professional one. Our communication will be during our sessions only.  We will not develop a social relationship. In a professional relationship, sexual intimacy is never appropriate and should be reported to the board. This is for your best interest and is stated in the ethical guidelines for licensed professional counselors.
    The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice, licensed professional counselors, and unlicensed individuals who practice psychotherapy.
    The agency within the Department that has responsibility specifically for licensed and Unlicensed Psychotherapists are the Department of Regulatory Agencies, Mental Health Section, 1560 Broadway, Suite 1350, Denver, Colorado 80202, and (303) 894-7766.
Confidentiality:
The information we discuss as client and counselor is confidential. However, there are a few exceptions that I am not permitted to keep information confidential. Colorado State Law states: the information disclosed to me is privileged communication and cannot be disclosed in any court of competent jurisdiction without the consent of the person to whom the testimony sought relates. The exceptions to the general rule of legal confidentiality are listed in Colorado statures (C.R.S. 12-43-218). Please be aware there are exceptions to that rule.
 
Exceptions of confidentiality:
1.    Any evidence or disclosure by the client of perpetrating child or elderly abuse must be reported to authorities.
2.    If an individual intends to harm another human being or him/herself, I must report it to authorities.
3.    Certain court orders may require disclosure of certain material covered in our sessions.
4.    Consultation and supervision with other professionals to aid in your treatment process.
    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.  If you request treatment information from me, I may provide you with a treatment summary, in compliance with Colorado law and HIPAA Standards.
DISCLOSURE REGARDING DIVORCE AND CUSTODY LITIGATION
If you are involved in divorce or custody litigation, my role as a therapist is not to 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.
Although there are several therapists at A Children’s Counseling Center, each of us has a separate and independent private practice.
We have agreed to a fee of _____ per session. Payment is expected in full at time of service. I require a 24- hour cancellation; otherwise you will be charged the full fee for a missed appointment. If you choose to pay by credit card I will add an additional 3% to your fee.
I will be consulting with Linda Klein, my supervisor, and Jeff Rinsky, MD. I may discuss personal information, in a non-disclosive manner.
By signing below you agree that you have read and understood the above information and that you are consenting to treatment with Suzanne Simon. This document will become part of your file at my office. If you have any questions please address them with me during our first session. This document must be signed prior to our second session.
Thank you.


CLIENT: _____________________________ DATE: _________________________

CLIENT: ______________________________ DATE: _________________________

COUNSELOR: _________________________ DATE: __________________________
.