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2nd Star Counseling Disclosure Form

2nd Star Counseling Disclosure Form

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Published by AThompsonCO

Copyright and All Rights Reserved 2012

Copyright and All Rights Reserved 2012

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Categories:Types, Business/Law
Published by: AThompsonCO on Nov 19, 2012
Copyright:Attribution Non-commercial


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Star Counseling, LLCwww.2ndstarcounseling.com
Kathryn Raley, Psychotherapist PO BOX 277Secondary Education, B.S. Lafayette Colorado
Master’s Candidate, Regis University
80026Certificate counseling Youth and Adolescents 720-515-8796Certificate Candidate, Transpersonal CounselingNCC Kathryn@2ndstarcounseling.com
Client Rights Statement 
The practice of licensed or registered persons in the field of psychotherapy is regulated by the MentalHealth Licensing Section of the Division of Registrations. The Board of Registered PsychotherapistExaminers can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800. Youare entitled to receive information about the methods and techniques of therapy I use, duration of therapy (if known), fee structure, and my degrees, credentials, and licenses. You may seek a secondopinion from another therapist or terminate therapy at any time. My license number is NLC-1436.Every person carries an innate desire for balance and wellness in their life. They also carry the ability toachieve these goals. I am dedicated to assisting you in this process. In an open and honest manner, I willwork with you to find the answers to questions surrounding relationships, sadness and day to dayintentional living. Using techniques from client-centered therapy, my belief is in growth realizedthrough a relationship of realness, caring and listening. I see my approach as primarily analytical,attempting to create, using a symbolic approach, a dialectical relationship between consciousness andthe unconscious. We can use dreams and fantasy to increase awareness, as well as some bodyawareness for symptomatic relief. Play Therapy techniques encourage children in honest and openexpression of emotion through the language of play.You are entitled to receive information from your therapist about the methods of therapy, thetechniques used, the duration of your therapy (if known), and the fee structure. You can seek a secondopinion from another therapist or terminate therapy at any time.
Registered psychotherapist is a psychotherapist listed in the State's database and is authorizedby law to practice psychotherapy in Colorado but is not licensed by the state and is not requiredto satisfy any standardized educational or testing requirements to obtain a registration from thestate.
Certified Addiction Counselor I (CAC I) must be a high school graduate, complete requiredtraining hours and 1,000 hours of supervised experience.
Certified Addiction Counselor II (CAC II) must complete additional required training hours and2,000 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 clini
cal master’s degree and meet the CAC III
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 theprocess 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 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.In a professional relationship, sexual intimacy is never appropriate and should be reported to the boardthat licenses, registers, or certifies the licensee, registrant or certificate holder.
All information provided to me by you in our professional relationship is confidential except in thefollowing circumstances: (a) you sign a release of information for a specific individual or agency; (b) childor elder abuse; (c) you are in imminent danger to self or others; (d) subpoena of records in a criminalprocedure. Additionally, I may consult with a treatment team of supervisors and colleagues. Thepurpose of consultation is to enhance my ability to help you, and these individuals are required to followthe same standards of confidentiality previously described.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 asother exceptions in Colorado and Federal law. For example, mental health professionals are required toreport suspected child abuse to authorities. If a legal exception arises during therapy, if feasible, you willbe informed accordingly. The Mental Health Practice Act (CRS 12-43-101, et seq.) is available at:http://www.dora.state.co.us/mental-health/Statute.pdf . 
Electronic Media
I will always do my best to maintain confidentiality in electronic media, such as Skype, email andtelephone messages including but not restricted to voice and text messages. Due to the nature of everchanging technology, 100% confidentiality is not guaranteed.I keep notes electronically as well.

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