Disclosure Statement - Get Now DOC by rnrj9uO


									                  Dr. Heidi Nahum, Ph.D., Licensed Clinical Psychologist
                         755 Maleta Ln #202, Castle Rock, CO 80108
                                          (303) 909 - 5825

                                Disclosure Statement
                      Client Rights and Important Information

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), and my fee structure. Please ask if you
would like to receive this information.

You are entitled to seek a second opinion from another therapist or terminate therapy at any

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

You should know that the information provided by you during therapy sessions is legally
confidential. If the information is legally confidential, the therapist cannot be forced to
disclose the information without the clients consent. There are exceptions to the rule of legal
confidentiality. These exceptions are listed in the Colorado statutes (see section 12-43-218,
C.R.S., in particular). Exceptions to confidentiality include: threat of serious harm to self or
others (including: suicide, child abuse, homicide), grave disability or under court order.
Should one of these situations arise during the course of therapy it will be identified and

If you have any questions or would like additional information, please feel free to ask.

The Colorado Department of Regulatory Agencies is responsible for regulating the practice of
psychotherapy by both licensed and unlicensed providers. Any questions, concerns, or
complaints regarding the practice of mental health may be directed to:
State Grievance Board, 1560 Broadway, Suite #1340, Denver, Colorado 80202,
(303) 894-7766.

Dr. Heidi Nahum is a Licensed Clinical Psychologist practicing under Colorado License
Number 2134. She has a Ph.D. from The University of California, San Diego and San Diego
State University Joint Doctoral Program in Clinical Psychology which was awarded in 1995.
Dr. Heidi Nahum practices as an independent provider.

I have read the preceding information and understand my rights as a client.

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Client Signature                                        Date

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Therapist                                               Date

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