Healing for the Soul, PC Staff Disclosure Statement POB 25314, Colorado Springs, CO / SOUL(7685)

Transcription

1 HFTS Therapist Staff & Credentials: Client name: Healing for the Soul, PC Staff Disclosure Statement POB 25314, Colorado Springs, CO / SOUL(7685) Rev. Jayson L. Graves, M.MFT, Registered Psychotherapist Ø Registered Psychotherapist, Ordained Minister, HFTS Clinical Director & President; providing Individual and marital counseling & Pastoral Coaching; Ø Seattle Pacific University, 2002, Masters of Science, Marriage & Family Therapy; Northwest College, 1996, Bachelors of Arts, Behavioral Science (Biblical Studies emphasis); Ordination: Christian Church. Geremy F. Keeton, M.MFT, LMFT Ø Licensed Marriage & Family Therapist; providing individual, group & marital therapy; Ø Masters in Marriage & Family Therapy, 2001; Bachelor of Science Human Communication, 1998 Abilene Christian University, Abilene, TX. Jenni Uzri, Registered Psychotherapist Ø Registered Psychotherapist providing individual, group (for wives & moms) & relationship counseling; Ø University of Northern Colorado, Masters in Clinical Mental Health, 2015 (projected); Colorado Christian University, Colorado Springs, CO: B.A. in Psychology, Rev. Michael E. Ed Millard, LMFT Ø Licensed Marriage & Family Therapist, Ordained Minister; providing individual, group and marital therapy & Pastoral Coaching; Ø Seattle Pacific University, 2005, Masters of Science, Marriage & Family Therapy; Multnomah Bible College, 2003, Bachelors of Science, Biblical Theology and Educational Ministries. Nathan Havens, B.A., Registered Psychotherapist Ø Registered Psychotherapist & Intern; providing individual & group therapy; Ø Liberty University, B.A., Psychology, 2000; Masters of Arts, Professional Counseling, 2015 (projected). Regulation of Psychotherapists: 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 regulatory boards can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) The regulatory requirements for mental health professionals provide that a Licensed Clinical Social Worker, a Licensed Marriage and Family therapist, and a Licensed Professional Counselor must hold a master s 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 master s 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 1000 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 bachelor s 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 master s degree and meet the CAC III requirements. A Registered Psychotherapist is listed in the State 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. 1

2 Client Privileges and Important Information: Client name: The CO Department of Regulatory Agencies has the general responsibility of regulating the practice of licensed psychologists, licensed social workers, licensed professional counselors, licensed marriage and family therapists, licensed school psychologists practicing outside the school setting, and registered individuals who practice psychotherapy. The agency within the Department that has responsibility specifically for licensed and registered psychotherapists (authorized to practice psychotherapy in the state of Colorado, not licensed by the state and not required to satisfy any standardized education or testing requirements to obtain registration from the state) is the Department of Regulatory Agencies, Mental Health Section, 1560 Broadway, Suite #1350, Denver, CO 80202, (303) You are entitled to receive information from us about our methods of therapy, the techniques we use, the duration of your therapy (if we can determine it), and our fee structure. Please ask if you would like to receive this information. You can seek a second opinion from another therapist or terminate therapy at any time. In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the CO Department of Regulatory Agencies, Mental Health Section. Telephonic group and/or individual counseling provides a confidential means of relational healing that is effective for most issues. Please note that those who are actively suicidal, experiencing hallucinations or psychosis, or primarily seeking recovery from chemical dependency should not use telephonic counseling as their first course of action. During your initial assessment, a counselor will help you determine if telephonic counseling is an appropriate course of action at this time. Clients are required to re-up their therapy treatment plan agreement every 12 months so you agree to sign and return this document at that frequency over the course of your care. Appointment etiquette & billing: Appointments will be billed the business day previous to the appointment. Any changes to an appointment require 72 hours (3 business days ) notice. There are no refunds for appointments not kept or not rescheduled more than 72 hours business hours in advance. You are responsible for scheduling a new appointment if there has been a missed or cancelled meeting. Initial assessment appointments are billed at the time of booking and are non-refundable. Current rates: Therapist 45-50: session.5 session Jayson Graves $139 $74 Geremy Keeton $129 $64 Jenni Uzri $109 $59 Ed Millard $99 $54 Nathan Havens $69 $39 Confidentiality: Generally speaking, the information provided by and to a client during therapy sessions is legally confidential if the therapist is a licensed marriage and family therapist, a licensed social worker, a licensed professional counselor, a licensed psychologist, or a registered psychotherapist. If the information is legally confidential, the therapist cannot be forced to disclose the information without the client's consent. Information disclosed to a registered psychotherapist is privileged communication and cannot be disclosed in any court of competent jurisdiction in the State of CO without the consent of the person to whom the testimony sought relates. You also understand and agree that we will communicate about your treatment with the other 2

3 (Confidentiality continued): therapists and/or interns on the HFTS team and their respective clinical supervisors, as well as with each other as needed. In marriage and family counseling, the therapist holds a no secrets policy. All members of the couple or family system attending the sessions are treated equally and secrets are not kept by the therapist that requires deferential or discriminatory treatment of family members. So, for married couples who are both receiving treatment from the HFTS team it is understood that by signing this disclosure statement they are both agreeing to a release of information and that staff members may communicate with each other about their marriage, spouse and any relevant treatment issues therein so that we may better serve the couple as a therapeutic team and therefore, confidentiality is limited and not guaranteed in this context. Should a client have something they do not want their HFTS therapist to disclose to the rest of the staff, particularly to their spouse s HFTS coach or therapist, it needs to be communicated to that therapist and help@healingforthesoul.org in writing. Exceptions to Confidentiality: There are exceptions to the general rule of legal confidentiality: 1) lf you pose a serious physical danger to yourself or another person; 2) lf threats to national security are disclosed; 3) lf you disclose that you or another person have physically or sexually abused or molested a child, an incompetent person, or a disabled person; 4) lf you disclose that a child, an incompetent person, or a disabled person is suffering from neglect; 5) Subpoenaed testimony in criminal court cases and orders to violate privilege by judges in child-custody and divorce court cases are also exceptions. Since our relationship with you is of a professional, formal nature and therefore exists primarily on that level, you agree to respect the nature of this relationship and acknowledge that recommendations, feedback and opinions will be given to you as part of the therapeutic process. This information and all interactions between us are subject to the scrutiny of our clinical supervisor/s for the purpose of confidentially assisting us with your care. If you choose to participate in one of our teleconference groups, your therapeutic information is also subject and open to the confidential relationship between the HFTS staff for purposes of consultation. You also understand confidentiality cannot be completely assured for electronic communications such as s, facsimile and certain wireless phone methods. You agree to not hold us responsible or liable for any inadvertent breaches in confidentiality if you choose to communicate with us by such electronic/telephonic means. Referrals: If at any point, we determine that your circumstances are beyond our ability, training, or scope of practice or we come to believe that the therapy is not effective, we may refer you to another therapist. Addendum statement for clients addressing unwanted Same-Sex Attraction (SSA) issues: If part of your counseling needs includes addressing this issue in yourself or in your relationship with your spouse or loved one, here is some more information to consider; if this is not the case for you, please disregard: SSA or eroticism per se is not considered a mental illness by any of the major mental health organizations. Studies completed to date by researchers do not support any one particular theory for the origins of SSA and/or homosexual orientation. While there are no well-designed controlled outcome studies of therapies considered as reorientation, sexual identity in nature or even gay-affirmative therapies, --and therefore scientific results are inconclusive regarding effectiveness--there are also alternatives to receiving professional therapy (e.g., religious-based support groups). Recent studies have shown, however that faith-based programs can be helpful for some who pursue this option (Jones & Yarhouse, 2008) and request help with distress over these impulses, homosexual behavior, or life satisfaction. Conversely, our counseling is not appropriate for those clients who volitionally request homosexualityaffirmative counseling and a referral therein can be provided upon request. We help people according to their own self-determination with their own personally-held goals based on their own personal values and faith beliefs according to the following tenets and principles: 1. Since homosexuality, whether experienced behaviorally, as an orientation, identity or any combination therein is not a mental illness, it is not to be treated as such; 3

4 (SSA Addendum continued): 2. People seeking therapy for unwanted same-sex attractions should only do so of their own volition and for themselves, not under coercion or for the appeasement of others. Attempts to address an individual s own sense of discontent with their sense of sexuality should not be based on guilt, shame, or fear but rather a sense of what is authentically and personally desired; 3. Healing for the Soul does not practice conversion or Reparative Therapy or related therapy models nor do we attempt to change a client from a homosexual to a heterosexual. Rather, we simply help people bring their sexuality in alignment with their personal beliefs and with how they desire to live their lives sexually; 4. We do not pit homosexuality against heterosexuality or vice versa; 5. People who are content with their embrace of homosexuality should not be and are not told they are broken, or need to be fixed; 6. Our model of therapy does not seek to change sexual orientation per se; rather, we help those interested in orienting their sexuality towards the opposite sex insofar as the client desires this and/or desires to live celibately; 7. Parents are never to be blamed for their child s sexual behavior, orientation or identity. Rather, feelings of guilt, shame and/or conviction are dealt with in an appropriate therapeutic way according to the parent s goals; 8. We do not employ strange, controversial or questionable interventions or methods as shock therapy, holding or the like. The primary mode of therapy is talk, which we augment with family systems theory, cognitivebehavioral and biblically based self-care interventions a la 1 Thessalonians 5:23. Divorce and Custody Litigation: If you are involved in divorce or custody litigation, our role as therapists is not to make recommendations to the court concerning custody or parenting issues. By signing this Disclosure Statement, you agree not to subpoena any HFTS staff to court for testimony or for disclosure of treatment information in such litigation; and you agree not to request that we 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. Assessments: You may be asked to take one or several different kinds of inventories/tests during the course of treatment. These are used under the strictest confidentiality guidelines. These instruments are used as nonmedical, mental health diagnostic tools that can aid the overall treatment of your situation. Minors: In order to provide psychotherapy to a child less than 15 years of age, we are required to secure written permission for the custodial parent or legal guardian. In certain cases, you may be asked to provide documented court proof of custody indicating your legal right to sign such permission. In such cases, any legal parent or guardian of the child has the right to information about the therapy of their minor. Phone Contact/Emergencies: We provide non-emergency psychotherapeutic services by scheduled appointment. If we believe your psychotherapeutic issues are above our level of competence, or outside my scope of practice, we are legally required to refer, terminate, or consult. If, for any reason, you are unable to contact us by telephone and are having a true emergency, you may call the 24-hour Pikes Peak Mental Health crisis line at (719) or the crisis hotline in your area. Also you may call 911 or check yourself into the nearest hospital emergency room. Be aware that you may leave a voice mail message in a private and confidential mailbox at the above stated number for non-emergencies as well. Nutritional Supplements: HFTS functions as an Amen ecenter, directly distributing Dr. Daniel Amen s Nutraceutical supplement blends designed to support normal, healthy brain function especially around struggles germane to sexual addiction including but not limited to compulsivity, attention & focus problems, and mood issues like depression and anxiety. Any recommendations we make are for your consideration only and not to be construed as medical advice and you should always check with your doctor for their opinion. If you purchase supplements from HFTS either 4

5 (Nutritional Supplements continued): directly from our stock or through the amenclinics.com website using our ecenter discount code, you acknowledge you are doing so at your own volition, not under any duress and that any portion of your purchase that goes to HFTS in any form should not be considered a commission, feesplit or dual-relationship but rather the normal cost of providing the service and related products. If you have questions or would like additional information about anything above, please feel free to ask. I have read the preceding information (including pages 1-5 attached) and understand my rights as a client/patient. By signing below I acknowledge my understanding and agree to all the terms discussed in this disclosure statement. By signing this disclosure statement, I also agree to permit consultation and I provide release for my therapist to seek consultation with other psychotherapists or professionals as the need arises. Client Signature / Printed name: / (Spouses and family members or anyone speaking to the therapist must each sign their own separate, individual Disclosure Statement copies) Date: Custodial parent/s / Legal guardian/s signature/s / Printed name/s (For client under 15 y.o.): / Date: ***Please initial, sign and fax or scan/ all 5 pages along with photo ID to HFTS: (303) or info@healingforthesoul.org - Thank you.*** 5