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Disclosure Statement

The following describes how mental health information about you may be used and/or disclosed, and also rights you have as a client. Please review the following information carefully. 

In accordance with Colorado State Law 12-43-214, as your therapist, I must provide you with the following information about myself and your rights as my client.

1. Stephen Rhode, Registered Psychotherapist


    100 Arapahoe Ave, Suite 12, Boulder, Colorado 80302,  303-875-6713

 

2. I completed two years of my Master's degree in clinical Transpersonal Counseling Psychology at Naropa University where I was also trained as a certified mindfulness instructor. I am a Colorado Registered Psychotherapist (NLC0108618) 

 

3. 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 State Board of Licensed Professional Counselor Examiners can be reached at: 

 

Department of Regulatory Agencies

Division of Professions and Occupations

1560 Broadway, Suite 1350

Denver, CO  80202

(303) 894-7800

 

As to the regulatory requirements applicable to mental health professionals: 

  • A Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a masters degree in their profession and have two years (2000 hours) of post-masters supervised experience. 

  • A Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Licensed Professional Counselor Candidate (LPCC) must hold the necessary licensing degree and be in the process of completing the required supervised hours for licensure. 

  • A registered psychotherapist is a psychotherapist 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.

 

4.  You are entitled, to receive information from your therapist about the methods of therapy, the techniques used, the duration of your therapy, if known, and the fee structure.  You can seek a second opinion from another therapist or terminate therapy at any time. 

 

5.  In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant, or certificate holder.

 

6.  Generally speaking, the information provided by and to the client during therapy sessions is legally confidential and cannot be released without the client’s consent. There are exceptions to this confidentiality, some of which are listed in section 12-43-218 of the Colorado Revised Statutes, as well as other exceptions in Colorado and Federal law. 

As a mandatory reporter, I must comply with the following legal exceptions to confidentiality:

1. I am required to report any threat of imminent danger made by you to law enforcement and to the person(s) threatened.

2. I am required to initiate a mental health evaluation if you appear an imminent danger to yourself or others or appear gravely disabled as a result of a mental health disorder.

3. If I have cause to believe that a child under 18 has been or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that I make a report to the appropriate governmental agency. Once such report is filed, I may be required to provide additional information.

4. I am required to report any suspected threat to national security to federal officials.

5. I may be required by Court Order to disclose treatment information.

6. In some cases, if you are under the age of 18, you may not have full confidentiality.

7. I may be required to report if you are over the age of 18 and disclose that you were abused/

neglected by a person who is currently in a position of trust with a child AND there is reasonable cause to suspect that the person has subjected another child who is currently under the age of 18 to abuse/neglect or to circumstances or conditions that would likely result in abuse/neglect.

If a legal exception arises during therapy, if feasible, you will be informed accordingly.  

 

I also regularly consult about your treatment with my supervisor and other mental health professionals who are also bound by law to protect your confidentiality.


 

7.  My time is normally charged at $140.00 per 50-minute session. A reduced rate is available to those in need and is determined and agreed upon between therapist and client. 

Your signature states your agreement to such a rate which will be _______ per session. 

 

Group psychotherapy fees depend on the specific group and will be discussed in the consultation. 

 

8.  Access to records and the handling of requests for records should be discussed. 

 

Telephone calls of over 15 minutes in duration are charged at $120.00 per hour in 15-minute increments. Full payment is required at each session. In the case of insurance, full payment is requested at each session and you should request that insurance reimbursement is sent directly to you, the client. 

Availability

 

My normal office hours are by appointment only and per scheduled group sessions.  

In emergencies, please use this number to reach me: (303) 875-6713

If the emergency is life-threatening please dial 911. 

 

Please contact my office 48 hours in advance to cancel a scheduled appointment.  Failure to do so will result in a full fee charge. Insurance companies cannot be billed for non-canceled appointments.

 

I have read the preceding information, which has also been provided verbally, and I understand my rights as a client or as the client’s responsible party. 

Disclosure Agreement

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