Linda S. Klein, LPC, RPT/S, PC 4251 Date Street, Colorado Springs, 80917 (719) 538-3264
DISCLOSURE AND CONSENT FOR TREATMENT
Welcome!
I want to acknowledge your courage and strength for beginning this therapeutic process for your child and you. I have prepared this to help you understand what to expect and what rights you have as my client. I use a combination of play therapy, parent education, filial therapy (where I train parents to do therapeutic play with their child) and family play therapy. I am excited about working with you and your child!
Therapy sessions last for 50 minutes scheduled for once a week. This is to help your child develop a trust relationship with me that is key for success in therapy. Payments can be made at the end of each session. Cancelled appointments must be done prior to 24 hours (unless extenuating circumstances) and a regular fee will be assessed to those appointments canceled within 24 hours. Phone messages may be left at 538-3264; urgent messages can be left at 338-7612. I check my messages during weekdays and try to return phone calls within 24 hours. Due to the fact that I do not run an emergency practice, I encourage you to call 911 or go to the nearest hospital in case of an emergency.
The practices of licensed and unlicensed psychotherapists are regulated by the Department of Regulatory Services. If you have any concerns about your experiences in therapy that the therapist cannot answer contact:
STATE GRIEVANCE BOARD, 1560 Broadway Suite 1340, Denver, Colorado 80202 (303) 894-7766
CLIENTS RIGHTS
• You may seek a second opinion from another therapist or terminate therapy at any time.
• As a client you are entitled to receive information about the method of therapy and techniques used. You are entitled to know the duration of therapy and fee structure if known.
• In a professional relationship such as this, sexual intimacy is never appropriate and should be reported to the Grievance Board.
• 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 child abuse or neglect to law enforcement; (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; and (5) I may be required by Court Order to disclose treatment information. (6) In the case of non-payment for services in order for your name to be given to a collection agency.
I meet monthly with Dr. Rinsky, M.D. Sometimes I may share information about you and your child with other professionals during that consultation group.
Information may also be share with my billing company to collect payment from your insurance company.
Although several therapists provide services at A Children’s Counseling Center, each of us has a separate and independent private practice.
Credentials and Professional Organization
• Licensed Professional Counselor
• M.A. in Agency Counseling, University of Northern Colorado 1992
• CAPT – Colorado Association for Play Therapy President Elect
• APT – Association for Play Therapy
• RPT/S – Registered Play Therapist and Supervisor for other Play Therapist
• B.S. in Social Work, Indiana State University 1978
If you have any questions about anything stated above please let me know at any time!
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.
I have read the preceding information and understand my rights as a client/patient. I also acknowledge that I have received a copy of this Disclosure Statement.
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Client Signature/Legal Representative Date
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CONSENT FOR TREATMENT/NOTICE OF ACKNOWLEDGEMENT
I consent to the evaluation and treatment process with Linda S. Klein, M.A., LPC, PC and I understand that this process may include myself, my minor child, and/or other family members. I am aware that care and treatment is not an exact science and acknowledge that no guarantees have been make to me as the result of treatment.
PAYMENT AGREEMENT
UNINSURED CLIENT ONLY: I understand that the fee for this service is $_______ per client hour. I agree to pay $ _______ per client hour as follows:
I will begin counseling on _____________. I understand that I can be billed for the amount of my agreed upon full client hour upon failing to miss an appointment without proper cancellation.
Counseling services are often considered a medical expense and are frequently covered by health insurance which requires a diagnostic determination. I do not, however, assume a contractual agreement with your insurance company. In accepting counseling services, clients agree to incur financial responsibility for those services.
INSURANCE/THIRD PARTY ONLY: I understand that the fee for this service is $_________ per client hour. I agree that I will be responsible for all moneys not covered by my insurance plan unless otherwise agreed to as follows:
I understand that I can be billed for the amount of my agreed upon full client hour upon failing to miss an appointment without proper cancellation.
I agree to the preceding relevant paragraphs.
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Print Client Name Date
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Client Signature Date
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Client or Witness Signature Date
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Signature of Legal Guardian Date
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Therapist Signature Date