Colorado Springs Office 3210 E. Woodmen Rd., #100 Colorado Springs, CO, Denver Office 837 Sherman St. Denver, CO 80203

Transcription

1 Colorado Springs Office 3210 E. Woodmen Rd., #100 Colorado Springs, CO, Denver Office 837 Sherman St. Denver, CO Welcome to my practice. I am honored that you are giving me the opportunity to be of help to you. It is my belief that the foundation of effective therapy is a solid relationship between a therapist and a client. I strongly believe you should feel comfortable with the therapist you choose. To help you decide if I will be a good fit for your needs, this document contains important information about me and the professional services I offer. As you read this form, I welcome you to note any questions, concerns, or suggestions you might have. I would be happy to discuss these with you at our next meeting. ABOUT ME I have a Doctorate in Counseling Psychology from the University of Northern Colorado. My training program was accredited by the American Psychological Association, and included a year-long internship. Additionally, I completed a Master s Degree in Community Counseling and a Bachelor s Degree in Psychology. I am a licensed psychologist in the state of Colorado and my license number is Also, I am an active member of the American Psychological Association. I have 12 years of experience in the mental health field and have worked in a variety of settings. I am trained and experienced in individual therapy, couples therapy, and family therapy. I also provide consultation services and supervision to therapists in training. I have been trained to work with adults, adolescents, or children. There are several different approaches to therapy that I have been trained in, and may use in my work with clients. My primary approach with clients is based on Cognitive Behavioral Therapy (CBT). Cognitive Behavioral Therapy has been shown to be an effective form of treatment for many different mental health concerns, some of which include depression, anxiety, eating disorders, etc. I also integrate techniques from Interpersonal and Humanistic approaches, Dialectical Behavioral Therapy, Motivational Interviewing, and Solution-Focused Therapy. Additionally, I have been trained in Eye Movement Desensitization and Reprocessing (EMDR). I specialize in the treatment of eating disorders and body image concerns. At the same time, I am also considered a generalist, which means that I am qualified to work with all types of concerns. My special interest areas include women s mental health, anxiety, depression, relationship issues, family issues, grief and loss, trauma, sexual identity, life transitions, and identity development. I am an independent practitioner and am not legally or professionally affiliated with any other mental health professional.

2 ABOUT PSYCHOTHERAPY I view therapy as a collaborative partnership between therapist and client. I expect us to plan our work together. I value your input and will actively seek to understand factors that can contribute to your success in therapy. Additionally, I would like to have input from you on how you feel you are progressing in therapy, or areas that you feel are not being addressed. From time to time, we will look together at our progress and goals. If we think we need to, we can then change our treatment plan, its goals, or its methods. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. At times, I will ask you to practice things we are working on outside of our meetings. I might ask you to do exercises, keep records, and read to deepen your learning. As with any powerful treatment, there are some risks as well as many benefits associated with participation in therapy. One risk involves the possibility that clients will have uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other negative feelings. Clients may recall unpleasant memories. These feelings or memories may bother a client at work or in school. Sometimes, too, a client s problems may temporarily worsen after the beginning of treatment. Most of these risks are to be expected when people are making important changes in their lives. Finally, even with our best efforts, there is a risk that therapy may not work out well for you. While you consider these risks, you should know also that the benefits of therapy have been shown by scientists in hundreds of well-designed research studies. People who are depressed may find their mood lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have a chance to talk things out fully until their feelings are relieved or the problems are solved. Clients relationships and coping skills may improve greatly. They may get more satisfaction out of social and family relationships. Their personal goals and values may become clearer. They may grow in many directions as persons, in their close relationships, in their work or schooling, and in the ability to enjoy their lives. I do not take on clients I do not think I can help. Therefore, I will enter our relationship with optimism about your progress. I highly value the relationships I form with clients. However, because of my ethical and legal obligations, there are limits to our relationship I d like you to understand. In order to be most helpful to you, I can only be your therapist. I cannot be a close friend to or socialize with any of my clients, and I cannot be a therapist to someone who is already a friend. I can never have a sexual or romantic relationship with any client during, or after, the course of therapy. Sexual intimacy between a client and therapist is never appropriate and is illegal in Colorado. Please report this to the below address if this has ever happened to you.

3 ABOUT YOUR RIGHTS AS A CLIENT As a client seeking mental health services, you have certain rights. These include your right to seek a second opinion from another therapist or your right to terminate this therapy at any time. You are also entitled to receive information regarding the methods of therapy, techniques used, the duration of therapy, if known, and the fee structure. Please ask if I do not fully provide you with this information or if you have any questions. The practice of psychology in Colorado is regulated by the Colorado Department of Regulatory Agencies. The agency within the Department that has responsibility for licensed and unlicensed psychotherapists is the Department of Regulatory Agencies. Any questions, concerns, or complaints regarding your mental health treatment may be directed to: ABOUT OUR APPOINTMENTS State Grievance Board 1560 Broadway, Suite 1370 Denver, Colorado Phone: The very first time I meet with you, we will need to give each other much basic information. I usually schedule minutes for this first meeting. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If you decide to begin therapy with me, we will usually schedule one 50-minute session per week at a time we agree on. There may be times when sessions may be longer, or more or less frequent depending on your course of treatment. We can schedule meetings for both your convenience and mine. An appointment is a commitment to our work. We agree to meet at my office and to be on time. If I am ever unable to start on time, I ask your understanding. I also assure you that you will receive the full time agreed to. If you are late, we will probably be unable to meet for the full time, because it is likely that I will have another appointment after yours. A cancelled appointment delays our work. I will consider our meetings very important and ask you to do the same. Please try not to miss sessions if you can possibly help it. When you must cancel, please give me as much notice as possible. PROFESSIONAL FEES AND PAYMENT I require payment by credit card, cash, or check at the time of service. If payment is not rendered in a timely fashion and I am unable to collect my fee, I may in some cases employ the services of a collection agency. In case a check does not clear, the fee for returned checks is $50. My current regular fees are below. You will be given advance notice if my fees should change.

4 Regular therapy services: My fee for a standard 50-minute therapy session is $ Please pay for each session at its end. I have found that this arrangement works best. It also allows me to keep my fees as low as possible, because it cuts down on my bookkeeping costs. Other payment or fee arrangements must be worked out before the end of our first meeting. Telephone consultations: I believe that telephone consultations may be suitable or even needed at times in our therapy. If so, I will charge you our regular fee, prorated over the time needed. If I need to have long telephone conferences with other professionals as part of your treatment, you will be charged for these at the same rate as for regular therapy services. If you are concerned about all this, please be sure to discuss it with me in advance so we can set a policy that is comfortable for both of us. Of course, there is no charge for calls about appointments or similar business. Extended sessions: Occasionally it may be better to go on with a session, rather than stop or postpone work on a particular issue. When this extension is more than 10 minutes, I will tell you, because sessions that are extended beyond 10 minutes will be charged on a prorated basis. Other services: I charge $130 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include report writing, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. I realize that my fees involve a substantial amount of money, although they are well in line with similar professionals charges. For you to get the best value for your money, we must work hard and well. Because I expect all payment at the time of our meetings, I do not send bills. If you would like a statement of the services I have provided to you, please let me know. A statement can be used for health insurance claims, as described in the next section. It will show all of our meetings, the charges for each, and how much has been paid. CANCELLATIONS I will reserve a regular appointment time for you into the foreseeable future. I also do this for my other clients. Therefore, I am rarely able to fill a cancelled session unless I have several weeks notice. If you are unable to keep an appointment, please notify me as soon as you become aware of this fact. If you cancel or miss an appointment without providing 24-hour notice, you will be billed for the entire session. Emergency situations are exceptions to this

5 policy, and will be evaluated and discussed in the context of your treatment on a case-by-case basis. INSURANCE Because I am a licensed psychologist, many health insurance plans will help you pay for therapy and other services I offer. Since health insurance is written by many different companies, I cannot tell you what your plan covers. It is very important that you find out exactly what mental health services your insurance policy covers. Please read your plan s booklet under coverage for Outpatient Psychotherapy or under Treatment of Mental and Nervous Conditions. Or call your employer s benefits office to find out what you need to know. I am not a member of any health insurance plans or panels. However, I am happy to supply you with all of the documentation necessary to file an out-of-network provider claim including, standard diagnostic and procedure codes for billing purposes, the times we met, my charges, and your payments. You can use this to apply for reimbursement. If you choose to submit this to your insurance for reimbursement, it is your responsibility to pursue the claim. IF YOU NEED TO CONTACT ME I am often not immediately available by telephone. While I am often in my office, I do not take calls when I am with a client. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If, during our work together, an emergency does occur which requires immediate attention, please call 911 or go to your nearest hospital for assistance. I urge you to inform me of these events as they may impact your therapy. It is important that you determine the level of emergency care that you would like to have in a therapist. My practice is not designed to help those who require 24-hour care or crisis and emergency care. In the event of an emergency, it may be necessary for you to contact another health care provider. If this does not seem to meet your needs, please let me know and I will provide you with the names of therapists who provide 24-hour care. IF I NEED TO CONTACT SOMEONE ABOUT YOU If there is an emergency during our work together, or I become concerned about your personal safety, I am required by law and by the rules of my profession to contact someone close to you perhaps a relative, spouse, or close friend. I am also required to contact this person, or the authorities, if I become concerned about your harming someone else. Please write down the name and information of your chosen contact person in the blanks provided:

6 Name: Address: Phone: Relationship to you: ABOUT CONFIDENTIALITY Confidentiality is an important component of therapy and one that I take very seriously. I will treat all the information you share with me with great care. It is your legal right that our sessions and my records about you be kept private. That is why I ask you to sign a release-ofinformation form before I can talk about you or send my records about you to anyone else. In general, I will tell no one what you tell me. I will not even reveal that you are receiving treatment from me. In all but a few rare situations, your confidentiality (that is, our privacy) is protected by federal and state laws and by the rules of my profession. Here are the most common cases in which confidentiality is NOT protected: If you were sent to me by a court or an employer for evaluation or treatment, the court or employer expects a report from me. If this is your situation, please talk with me before you tell me anything you do not want the court or your employer to know. You have a right to tell me only what you are comfortable with telling. Are you suing someone or being sued? Are you being charged with a crime? If so, and you tell the court that you are seeing me, I may then be ordered to show the court my records. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. Please consult your lawyer about these issues. If you make a serious threat to harm yourself or another person, the law requires me to try to protect you or that other person. These actions may include notifying the potential victim, contacting the police, and/or seeking hospitalization for the client. If my client threatens to harm or kill herself/himself, I may be obligated to call the police, seek hospitalization for him or her, or to contact family members or others who can help provide protection. If I believe that a child, elderly person, or disabled person is being abused or neglected, I must file a report with the appropriate state agency. These situations rarely occur in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action. There are two other situations in which I might talk about part of your case with another therapist. I ask now for your understanding and agreement to let me do so in these two

7 situations. First, when I am away from the office for a few days, I have a trusted fellow therapist cover for me. This therapist will be available to you in emergencies. Therefore, he or she needs to know about you. Of course, this therapist is bound by the same laws and rules as I am to protect your confidentiality. Second, I sometimes consult other therapists or other professionals about my clients. This helps me in giving high-quality treatment. These persons are also required to keep your information private. Your name and other identifying information will be changed or omitted, and they will be told only as much as they need to know to understand your situation. Clients Under the Age of Eighteen If you are under 18 years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that gives up their access to your records. If they agree, I provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. Before giving them any information (except in the cases of imminent danger), I will do my best to discuss the matter with you and to handle any objections you may have about what I am prepared to discuss. Except for situations like those I have described above, I will always maintain your privacy. If your records need to be seen by another professional, or anyone else, I will discuss it with you. If you agree to share these records, you will need to sign an authorization form. This form states exactly what information is to be shared, with whom, and why, and it also sets time limits. Please ask me if you have any questions regarding confidentiality.

8 CONSENT FOR TREATMENT I acknowledge that I have received, have read (or have had read to me), and understand the preceding information regarding Dr. Angie Dunn s degrees, credentials, practice, and privacy policies. I have read the preceding information in full and understand my rights as a client. I have had all my questions answered fully. I do hereby seek and consent to take part in the treatment with Dr. Angie Dunn. I agree to play an active role in this process. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist. I am aware that I may seek a second opinion or stop my treatment with this therapist at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment (for example, if my treatment has been court-ordered, I will have to answer to the court). I know that I must call to cancel an appointment at least 24 hours before the time of the appointment. If I do not cancel and do not show up, I will be charged for that appointment. My signature below shows that I understand and agree with all of these statements. I consent to therapy, including assessment, evaluation, treatment, and/or referral. Signature of client (or person acting for client) Printed name Date Relationship to client (if necessary) I truly appreciate the chance you have given me to be of professional service to you, and look forward to a successful relationship with you. If you are satisfied with my services as we proceed, I (like any professional) would appreciate your referring other people to me who might also be able to make use of my services. I, Angie Dunn, have discussed the issues above with the client (and/or his or her parent, guardian, or other representative). My observations of this person s behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent. Angie Dunn, Ph.D. Date Copy accepted by client Copy kept by therapist