Statement of Understanding
I look forward to beginning therapy with you. I appreciate your commitment to this process and the energy you bring to the changes you desire to make. In order to further clarify expectations, please read the entirety of this document in preparation for counseling. Note: The end of this document includes a Client Disclosure Statement. Please read and sign the last page. Bring the signed page to the first session and let me know if you have any questions.
Getting the most out of therapy.
Good therapy will be life changing! I will bring my best to support you in all your goals and changes. I come prepared to work with you. As you come prepared for therapy it will help you maximize your experience during the session. Reviewing your objectives and goals ahead of time, making notes about the sessions, and doing the assigned recommendations will reinforce your success. Studies have demonstrated that proactive clients benefit more from therapy, reach their goals sooner and finish their counseling more satisfied with their progress. Coming to a session unprepared may cause you to become frustrated with the process or feel you’re spinning your wheels.
If you have scheduled a typical 50 minute session I will let you know 5 minutes before our time is ending so we can wrap up without a rush. It is important for you to pace yourself during the session in order for you to maximize your time. Bringing up a crucial issue at the end of a session may mean it has to become the focus of the next session. Prioritizing what you want to discuss will help us both manage the time well.
What is accomplished “in sessions” should be substantial, but what happens “between sessions” is also significant. Working on your changes is a daily discipline. Making and sustaining the changes in your life will insure you keep your traction and get positive results. Developing an accountable plan (I will introduce a Growth Plan template) and following through on your goals will support an empowering process of change in the key areas of your life that you seek to improve.
Payments and Billing
Payments can be made using cash, check or credit card at the beginning of each session. It may save time if you are using a check to have that made out prior to the session. Sessions are 50 minutes, double sessions 100 minutes and so on. Because I collect payments each session I do not invoice. If you request a record of your sessions I can provide a document indicating dates of service and payments you have made, otherwise your checks or credit card receipts are your primary record.
While I am an in Network Provider within several insurance companies I am NOT able to provide insurance at this time.
Cancellations and Changing Appointment Times
If I schedule a session with you the entire time is reserved for you alone. When you cancel or change your appointment I need adequate time to schedule in another client or I will lose that opportunity as well as business revenue. The Cancellation Policy described in the Intake form is an industry standard expectation and will be applied if the cancellation is not made within the 24 hours (double sessions 48 hours). While no one likes being charged for missed sessions I will enforce this policy unless you have an adequate justification.
Inventories and Assessments
Inventories and personality assessments are important tools in self-understanding, relating to others more respectfully and effectively while moving the therapy along at a more efficient pace. While I provide many assessments at no charge, sometimes the testing used in therapy may involve an addition expense. I will let you know the rationale for any recommended inventories and if there are any costs involved.
The Parker office (10165 Quarry Hill Place) has parking limitations because this location is at my residence. Since the neighborhood covenants are strict, please park directly at the curb in front of my house (not ever across the street) or park in the North driveway. Please do not walk up to the front door as I may not be ready, Text me when you arrive and I will greet you at the door.
Whether it is taking a break or meeting for a final session, the postponement or termination of your counseling sessions should be the realization of your goals and a positive outcome. Good closure is beneficial and graduations should be celebrated! Termination can be initiated by either the client or the counselor and should be announced in advance of the final session in order that both parties may be prepared. Premature endings may thwart your goals and worsen your condition so I advise against endings that could have a less than positive outcome. To foster clarity, I appreciate knowing who is still an active client, if therapy is being postponed or if a client wants to end our working relationship.
Client Disclosure Statement
David L. Ragsdale LPC
1. The Colorado Department of Regulatory Agencies (“DORA”), Division of Professions and Occupations (“DOPO”) has the general responsibility of regulating the practice of Licensed Psychologists, Licensed Social Workers, Licensed Professional Counselors, Licensed Marriage and Family Therapists, Certified and Licensed Addiction Counselors, and registered individuals who practice psychotherapy. The agency within DORA that specifically has responsibility is the Mental Health Section, 1560 Broadway, Suite #1350, Denver, CO 80202, (303) 894-2291 or (303) 894-7800.
2. You, as a client, may revoke your consent to treatment or the release or disclosure of confidential information at any time in writing and given to David Ragsdale LPC.
3. Levels of Psychotherapy Regulation in Colorado include Licensing (requires minimum education, experience, and examination qualifications), Certification (requires minimum training, experience, and for certain levels, examination qualifications), and Registered Psychotherapist (does not require minimum education, experience, or examination qualifications.) All levels of regulation require passing a jurisprudence take-home examination. Certified Addiction Counselor I (CAC I) must be a high school graduate, complete required training hours and 1,000 hours of supervised experience. Certified Addiction Counselor II (CAC II) must complete additional required training hours and 2,000 hours of supervised experience. Certified Addiction Counselor III (CAC III) must have a bachelor’s degree in behavioral health, complete additional required training hours and 2,000 hours of supervised experience. Licensed Addiction Counselor must have a clinical master’s degree and meet the CAC III requirements. Licensed Social Worker must hold a master’s degree in social work. 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. Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a master’s degree in his or her 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. Registered Psychotherapist is a psychotherapist listed in Colorado’s database and is authorized by law to practice psychotherapy in Colorado but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state. Registered psychotherapists are required to take the jurisprudence exam.
CLIENT RIGHTS AND IMPORTANT INFORMATION:
1. As a client you are entitled to receive information from us about our methods of therapy, the techniques we use and our fees. Please ask if you would like to receive this information. It is the policy of our practice to collect all fees before services are rendered, unless you make arrangements for payment and we both agree to such an arrangement.
2. You are entitled to request restrictions on certain uses and disclosures of protected health information as provided by 45 CFR 164.522(a), however David Ragsdale LPC is not required to agree to a restriction request. Please review our Notice of Privacy Policies for more information.
3. You are entitled to seek a second opinion from another therapist or terminate therapy at any time. If you elect to terminate therapy before the completion of a contracted intensive counseling retreat or have purchased a package of counseling services David Ragsdale LPC is not obligated to refund any fees that have been have collected.
4.In a professional relationship (such as psychotherapy), sexual intimacy between a psychotherapist and a client is never appropriate. If sexual intimacy occurs it should be reported to DORA at (303) 894-2291, Mental Health Section, 1560 Broadway, Suite 1350, Denver, Colorado 80202; State Board of Licensed Professional Counselor Examiners.
5. Generally speaking, the information provided by and to a client during therapy sessions is legally confidential if the psychotherapist is a Licensed Psychologist, Licensed Social Worker, Licensed Professional Counselor, Licensed Marriage and Family Therapist, Certified and Licensed Addiction Counselor, or a Registered Psychotherapist. If the information is legally confidential, the psychotherapist cannot be forced to disclose the information without the client’s consent or in any court of competent jurisdiction in the State of Colorado without the consent of the person to whom the testimony sought relates.
6. There are exceptions to this general rule of legal confidentiality. These exceptions are listed in the Colorado statutes, C.R.S. §12-43-218. You should be aware that provisions concerning disclosure of confidential communications does not apply to any delinquency or criminal proceedings, except as provided in C.R.S § 13-90- 107. There are additional exceptions that we will identify as the situations arise during treatment or in our professional relationship. For example, we am required to report child abuse or neglect situations; we are required to report the abuse or exploitation of an at-risk adult or elder or the imminent risk of abuse or exploitation; if we determine that you are a danger to yourself or others, including those identifiable by their association with a specific location or entity, we are required to disclose such information to the appropriate authorities or to warn the party, location, or entity you have threatened; if you become gravely disabled, we are required to report this to the appropriate authorities. We may also disclose confidential information in the course of supervision or consultation in accordance with our policies and procedures, in the investigation of a complaint or civil suit filed against us, or if we are ordered by a court of competent jurisdiction to disclose such information. You should also be aware that if you should communicate any information involving a threat to yourself or to others, we may be required to take immediate action to protect you or others from harm. In addition, there may be other exceptions to confidentiality as provided by HIPAA regulations and other Federal and/or Colorado laws and regulations that may apply.
7. Additionally, although confidentiality extends to communications by text, email, telephone, and/or other electronic means, we cannot guarantee that those communications will be kept confidential and/or that a third-party may not access our communications. Even though we may utilize state of the art encryption methods, firewalls, and back-up systems to help secure our communication, there is a risk that our electronic or telephone communications may be compromised, unsecured, and/or accessed by a third-party.
“No Secrets” Policy:
8. When treating a couple or a family, the couple or family is considered to be the client. At times, it may be necessary to have a private session with an individual member of that couple or family. There may also be times when an individual member of the couple or family chooses to share information in a different manner that does not include other members of the couple or family (i.e. on a telephone call, via email, or via private conversation). In general, what is said in these individual conversations is considered confidential and will not be disclosed to any third party unless your therapist is required to do so by law. However, in the event that you disclose information that is directly related to the treatment of the couple or family it may be necessary to share that information with the other members of the couple or the family in order to facilitate the therapeutic process. Your therapist will use his best judgment as to whether, when, and to what extent such disclosures will be made. If appropriate, your therapist will first give the individual the opportunity to make the disclosure themselves. This “no secrets” policy is intended to allow your therapist to continue to treat the couple or family by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the couple or the family being treated. If you feel it necessary to talk about matters that you do not wish to have disclosed, you should consult with a separate therapist who can treat you individually.
9. In the case that David Ragsdale LPC becomes disabled during the period of counseling, die, or need an extended leave of absence (hereinafter “extraordinary event,”) Stan Eastin PhD of the LeaderCare Board of Directors will have access to my client files. If your therapist is unable to contact you prior to the extraordinary event occurring, a Mental Health Professional Designee will contact you and refer you for ongoing care. The purpose of the Mental Health Professional Designee is to continue your care and treatment with the least amount of disruption as possible. You are not required to use the Mental Health Professional Designee for therapy services, but the Mental Health Professional Designee can offer you referrals and transfer your client record, if requested.
10. David Ragsdale LPC may keep and store client information electronically on any laptop or desktop computer, and/or some mobile devices. In order to maintain security and protect this information, David Ragsdale LPC may employ the use of firewalls, antivirus software, changing passwords regularly, and encryption methods to protect computers and/or mobile devices from unauthorized access. David Ragsdale LPC may also remotely wipe out data on mobile devices if the mobile device is lost, stolen, or damaged. David Ragsdale LPC may use electronic backup systems such as external hard drives, thumb drives, or similar methods. If such backup methods are used, reasonable precautions will be taken to ensure the security of this equipment and it will be locked up for storage. David Ragsdale LPC may maintain the security of the electronically stored information through encryption and passwords. In addition, in order to maintain security of the electronically stored information.
AS A CLIENT:
You as a Client agree and understand the following:
1. I understand that David Ragsdale LPC may contact me to provide information about treatment alternatives or other health-related benefits and services that may be of interest to me.
2. I understand that there may be times when my therapist may need to consult with a colleague or another professional, such as an attorney or supervisor, about issues raised by me in therapy. My confidentiality is still protected during consultation by my therapist and the professional consulted. Only the minimum amount of information necessary to consult will be disclosed. Signing this disclosure statement gives my therapist permission to consult as needed to provide professional services to me as a client. I understand that I will need to sign a separate Authorization for Release of Information for any discussion or disclosure of my protected health information to another professional besides a colleague, supervisor or attorney retained by my therapist.
3. I understand that communications via email and text should be limited to administrative purposes and not used as an avenue for therapy. I understand that should I want Teletherapy, I will discuss my request with my therapist. I understand that it is in my therapist’s sole discretion whether to accommodate my request for Teletherapy. If Teletherapy is provided, David Ragsdale LPC will utilize a HIPPA approved platform for such Teletherapy.
4. I understand that my therapist does not accept personal Facebook, LinkedIn, Twitter, Instagram, and/or other friend/connection/follow requests via any Social Media. Any such request will be denied in order to maintain professional boundaries. I understand that David Ragsdale LPC has, or may have, a business social media account page. I understand that there is no requirement that I “like” or “follow” this page. I understand that should I “like” or choose to “follow” David Ragsdale LPC business social media page that others will see my name associated with “liking” or “following” that page. I understand that this applies to any comments that I post on David Ragsdale LPC page as well. I understand that any comments I post regarding therapeutic work between my therapist and I will be deleted as soon as possible. I agree that I will refrain from discussing, commenting, and/or asking therapeutic questions via any social media platform. I agree that if I have a therapeutic comment and/or question that I will contact my therapist through the mode I consented to and not through social media.
5. I understand that if I have any questions regarding social media, review websites, or search engines in connection to my therapeutic relationship, I will immediately contact my therapist and address those questions.
6. I understand my therapist provides non-emergency therapeutic services by scheduled appointment only. If, for any reason, I am unable to contact my therapist by the telephone number provided (303-324-6261) and I am having a true emergency, I will call 911, check myself into the nearest hospital emergency room, or call Colorado’s Crisis Hotline (844) 493-8255. David Ragsdale LPC is not always able to provide after-hours or outside the intensive services without an appointment. If I must seek after-hours treatment from any counseling agency or center, I understand that I will be solely responsible for any fees due. I understand that if I leave a voicemail for my therapist on the phone number provided, my therapist will return my call by the end of the next business day, excluding holidays and weekends.
7. If my therapist believes my therapeutic issues are above his or her level of competence or outside of his or her scope of practice, my therapist is legally required to refer, terminate, or obtain consultation.
8. I understand that this form is compliant with HIPAA regulations and no medical or therapeutic information or other information related to my privacy, will be released without permission unless mandated by Colorado law as described in this form and the Notice of Privacy Policies and Practices. By signing this form, I agree and acknowledge I have received a copy of the Notice or declined a copy at this time. I understand that I may request a copy of the Notice at any time.
9. I understand that if I have any questions about David Ragsdale LPC or my therapist’s methods, techniques, or duration of therapy, fee structure, or would like additional information, I may ask at any time during the therapy process. By signing this disclosure statement I also give permission for the inclusion of my partners, spouses, significant others, parents, legal guardians, or other family members in therapy when deemed necessary by myself or my therapist. I agree that these parties will have to sign a separate Consent for Third-Party Participation Agreement or may have to sign a separate disclosure statement in order to participate in therapy.
10. I understand that should I choose to discontinue therapy for more than sixty (60) days by not communicating with my therapist, my treatment will be considered “terminated.” I may be able to resume therapy after the sixty (60) day period by discussing my decision to resume therapy services. Ability to resume therapy after sixty (60) days will depend upon my therapist’s availability and will be within his or her sole discretion. This disclosure statement will remain in effect should I resume therapy if one (1) year has not elapsed since my last session. However, I may be asked to provide additional information to update my client record. I understand “discontinuing therapy” means that I have not had a session with my therapist for at least sixty (60) days, unless otherwise agreed to in writing.
11. There is no guarantee that psychotherapy will yield positive or intended results. Although every effort will be made to provide a positive and healing experience, every therapeutic experience is unique and varies from person to person. Results achieved in a therapeutic relationship with one person are not a guarantee of similar results with all clients.
12. Because of the nature of therapy, I understand that my therapeutic relationship has to be different from most other relationships. In order to protect the integrity of the counseling process the therapeutic relationship must remain solely that of therapist and client. This means that my therapist cannot be my friend, cannot have any type of business relationship with me other than the counseling relationship (i.e. cannot hire me, lend to or borrow from me; or trade or barter for services in exchange for counseling); cannot have any kind of romantic or sexual relationship with a former or current client, or any other people close to a client, and cannot hold the role of counselor to his or her relatives, friends, the relatives of friends, people known socially, or business contacts.
Maintenance of Client Record.
As a client, you may request a copy of your Client Record at any time. In accordance with the Rules and Regulations of [your respective DORA board], we will maintain your client record (consisting of disclosure statement, contact information, reasons for therapy, notes, etc.) for a period of seven (7) years after the termination of therapy or the date of our last contact, whichever is later. We cannot guarantee a copy of your Client Record will exist after this seven-year period. The signature below affirms that the preceding information has been provided to us in writing. If I am unable to read or have no written language, an oral explanation accompanied the written copy.
I understand my rights as a client and should I have any questions, I will contact my therapist David Ragsdale LPC.
Client Printed Name:________________________________Date of Birth_____________
Signature___________________________ DATE _______________
Client Printed Name:________________________________Date of Birth_____________
Signature___________________________ DATE _______________
Therapist _____________________________________ DATE_________________