Linda S. Klein, LPC, RPT/S, PC 4251
Date Street, Colorado Springs, 80917
(719) 538-3264
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
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 ChildrenÕs Counseling Center, each of us has a separate
and independent private practice.
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 familyÕs 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.
_________________________________ ________________________
Client Signature/Legal Representative Date
__________________________________ ________________________
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.
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