Disclosure Statement / Nature of My Practice

Disclosure Statement Marguerite Harper, M.A, LPC 12600 W. Colfax Ave., #C-430 Lakewood, CO 80215 Tel:303-716-3577 Fax:303-986-0304 Email: [email protected]

Purpose The purpose of the Disclosure Statement is to inform you of your rights and responsibilities as a client and to fulfill the requirements of the State of Colorado Department of Regulatory Agencies, for the provision of Licensed Professional Counseling services.

My Degrees M.A. University of Colorado @ Denver B.A. University of Colorado @ Denver Counseling Psychology, 1997 Communications, 1988

Licensure I am licensed in the state of Colorado as a Licensed Professional Counselor (License # 2291)

Regulation of Psychotherapy The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of licensed and unlicensed psychotherapists. If you have any complaints or concerns regarding a psychotherapist, please express your concerns to the Agency. The agency within the Department that has responsibility specifically for licensed and unlicensed psychotherapists is the State Grievance Board, 1560 Broadway, Suite #1340, Denver, CO 80202. (303) 894-7766.

Client Rights and Information

1. You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy (if I can determine it.) Please ask if you would like this information. 2. You can seek a second opinion from another therapist or terminate therapy at any time. 3. 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 State Grievance Board. 4. If you ever become involved in a divorce or custody dispute or you have to appear in court for any reason and would like me to make a statement on your behalf, please be informed and agree that I will not provide evaluations or expert testimony in court. My recommendation is that your hire a different mental health professional for any evaluations or expert testimony you require. 5. Generally speaking, information by and to a client during therapy sessions is legally confidential. If the information is legally confidential, the therapist cannot be forced to disclose the information without the client’s consent (see Privacy Statement below.)

Privacy Statement

There are exceptions to the general rule of legal confidentiality. You should be aware that, except in the case of information given to a licensed psychologist, legal confidentiality does not apply in a criminal or delinquency proceeding. Client records are protected under State and Federal confidentiality regulations and cannot be disclosed without the client’s (your) written permission unless provided for in these regulations including, 1. admission of child abuse (you or someone else) or vulnerable adult abuse, 2. threat of serious imminent harm to yourself and or others, 3. if there is a court ordered subpoena requiring the release of information. I understand that information may be reviewed in peer consultation for my benefit; insurance companies and employee assistance programs, if appropriate, may also receive my information when required for payment.

Financial Agreement & Office Policies

Standard Service Fee

Through my many years of clinical practice, I have been increasingly moving away from a “medical model” of psychotherapy to a more holistic, wellness model. Unfortunately, insurance companies require therapists to provide a psychiatric diagnosis for every client that uses their insurance to reimburse for each counseling session. This diagnosis is also a permanent part of your medical health record. This is why many clients choose to not use their insurance for therapy services. Therefore, I offer both self- pay and insurance options.

 Individual 45 minute session is $120 dollars, unless we are contracted under insurance, or an EAP.

 Couple 45 minute session is $120 dollars, unless we are contracted under insurance, or an EAP.

 Couple 90 minute session (non-insurance) is $150 dollars.

 By exception, a negotiated fee will be considered.

 I accept Cash, Check, Visa and MasterCard and flex spending credit card accounts.

 If you require any documentation in the form of letters or chart summaries, my fee is $120 per hour and will be pro-rated accordingly. This fee is generally NOT covered under insurance and is due upon receipt of the documentation.

 Full payment or co-payment is due at each session unless other arrangements have been made. By signing below you acknowledge that you are responsible for all insurance deductibles and any pre-authorizations for treatment.

 I also have an option of using legal means to secure an overdue payment. This may involve hiring a collection agency or seeking legal resources which requires me to disclose confidential information.

Cancellation Policy

 Appointment times are reserved for you. If a cancellation is unavoidable, then a 24 hours advance notice is required so I can offer the time to another client. Cancellations less than 24 hours notice will result in a $50 charge (except in the case of an emergency or extreme weather.) This fee cannot be billed to your insurance. Other Information

 Counseling is a collaborative process and it involves a relationship between client and counselor. Together we will discuss your goals and expectations for counseling and what you hope to achieve. It is important that we are open and honest with each other.  As I am not affiliated with any mental health agencies, I do not have 24 hour coverage. If you believe the nature of your situation requires you to get in contact with me outside of my business hours and you cannot leave a confidential message that will be returned within the next business day, perhaps your counseling arrangement might require someone with more coverage abilities. Please let me know and I will help you find someone right away.

 Sometimes my care does not help everyone. In this situation, please let me know how you are feeling, if we need to focus in a different direction or if you need a referral for another counselor. My goal is to make sure you are getting the best treatment possible and sometimes that may require another counselor for you – just let me know how I can help.

 When counseling couples: I do not keep secrets from each person in the couple as I feel it takes away from the nature of the counseling relationship. So, please do not tell me anything you do not want your partner to hear unless there is a threat to safety.

I have read and I understand my rights and responsibilities in this document. I have been informed of Marguerite Harper’s degrees and licensure and nature of her practice.

Client/Parent or Guardian Signature Date

Counselor Date