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					www.frontrangecounselingcenter.com

Welcome!
The counselors of Front Range Counseling Center are honored to have the opportunity to work with you. This packet contains information and forms that your counselor will need to have on file for the first meeting. Please review and complete the following documents: 1. Disclosure Statement — to be reviewed and signed. 2. Client Information Form — to be completed and returned to counselor. 3. Colorado Notice Form of HIPAA Legislation — to be reviewed and signed. **All signed forms are to be returned to Front Range Counseling Center, Inc. Please retain a copy of this information for your records. Front Range Counseling Center

Denver Southeast Office

Littleton Office

Front Range Counseling Center 7200 E. Hampden Ave., Suite 105 Denver, CO 80224 303-933-5800
(Located one mile east of Interstate 25 and approximately one mile west of Tamarac Dr. on the south side of East Hampden Ave.)

Front Range Counseling Center 6901 S. Pierce Street, Suite 235 Littleton, CO 80130 303-933-5800
(Located north of Ken Caryl Ave and south of West Coal Mine Ave. Approximately one mile south of Columbine High School)

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Front Range Counseling Center, Inc.
Thank you for deciding to seek counseling at Front Range Counseling Center, Inc. The following information will help you understand many of the details about your therapy here. A primary commitment of Front Range Counseling Center, Inc. (FRCC) is to provide quality time-effective treatment to individuals, couples and families regardless of age, race, sex, or religious affiliation. Professional Christian counseling and the use of spiritual resources are available for patients who request it. FRCC staff members are further committed to the patient’s rights of information regarding office policy, non-discrimination, confidentiality, consent and competent service. In keeping with this policy, we have listed below our various office policies for your information. Please read through these, ask any questions you may have and sign on the other side. Thank you for allowing us to serve you. You may call (303) 933-5800 regarding any questions you may have (i.e. billing, appointments, etc.). After hours, leave a voice mail message with your contact information and you will be contacted the next business day. FRCC is not a 24 hour counseling center. In an emergency, please call 911. FULL NAMES AND CREDENTIALS OF THERAPISTS: Kevin B. Leapley, MA, LPC, CSAT Steven P. Marks, MA, LPC, NCC Shannon Rants, MA Charlton Clarke, MA Rachel Moses, MA Brooke Epperhart, MA Abby Blacklock, MA, NCC Andrew Jerusik, MA, LPC Kathy Taussig, MA, LPC Christine Denlinger, MA, NCC Amber Wong, MA Sam Jolman, MA Kim Jones, MA Richard Carter, BS Ken Curry, MA Garry Nutter, MA, NCC Lizzy Wagner, MA, NCC Claudette Siekmeier, MA, NCC Linnaya Widhalm, MA, NCC, CACII Suzanne L. Lewis, RN, MS, Ph. D., LPC Anne Gonsoulin, MPS, LPC Trisha Swinton, MA, LPC, LMFT Suzy Newman, MA

Please be aware that the therapists of FRCC are each independent mental health professionals, with their own private practices. While FRCC has carefully selected each counselor, they are not employees of FRCC but rather are independent counseling businesses. The practice of both licensed and unlicensed persons in the field of psychotherapy is regulated by the Colorado State Departments of Regulatory Agencies. All therapists at FRCC have been trained in a variety of specific methods of treatments and will determine what approaches and techniques might be most effective with your particular needs (results cannot be guaranteed). Professional Christian therapy is provided for patients expressly requesting it. Although the exact length of treatment is difficult to predict, your therapist will be glad to discuss his/her average treatment duration for conditions similar to yours. Your therapist will also be willing to discuss what other treatment options might be available and the possible effectiveness of those alternatives. You may, at any time, seek a second opinion from another therapist and/or may terminate therapy at any time without penalty. Consistent with the established moral and ethical position of FRCC, recent Colorado law requires that any individual seeking any counseling services must be informed that sexual contact between patient and therapist is not a part of any recognized therapy. Sexual intimacy between patient and therapist is never appropriate, is illegal, and should be reported in writing to the Department of Regulatory Agencies, Mental Health Section, 1560 Broadway, Suite 1340, Denver, Colorado 80202, or by phone at 303-8947766. If you have any concerns or complaints about licensed or unlicensed mental health practitioners, you can contact the State Grievance Board. SESSIONS Sessions are typically scheduled for 50 minutes at a frequency to be determined by the counselor and client. You may be referred to a health care provider or support group in the community, or a combination of the two if necessary. It is essential for you to feel comfortable with your counselor. PAYMENT POLICY FRCC counselors see clients on a fee-for-service basis only. The client/parent is responsible for payment in full at the time of each session. FRCC counselors charge $90.00 per fifty (50) minute session. Our policy is for each person receiving counseling or testing services to pay for such service at the time the professional services are rendered. Any other arrangements must be made in advance. A $25 administrative fee will be charged on all checks that are returned for non-sufficient funds.

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Front Range Counseling Center, Inc.
Phone consultations are billed in 15-minute increments ($25.00 minimum). All calls over five minutes will be billed accordingly. In case of an emergency, please call 911. For clients that request an emergency counseling session on a counselor’s regularly scheduled off day, the cost will be $135 per 50-minute session. Any additional work by a counselor, such as providing summary notes to a third party, will be billed at a prorated rate based on our current individual session rate ($90.00 or $1.80 per minute). Please note: Charges for testing services and educational resources are in addition to the regular per-session fee. INSURANCE Many insurance plans reimburse for some portion of psychotherapy. Please direct questions about reimbursement amounts and timeliness to your insurance company. The FRCC counselors are not contracted (in network, preferred provider) with any insurer. We will provide you with a receipt for the counseling service at your appointment that may be used to submit for reimbursements if you choose. Please note that we do not complete any insurance paperwork. CANCELLATIONS We understand that it may, at times, be necessary to cancel an appointment. To help us be most efficient and responsible in the use of our time, we require that any changes or cancellations be made at least 24 hours in advance. Any changed, cancelled, or missed appointment with less than 24-hour notice will be charged $90.00.

CONFIDENTIALITY The confidentiality of the counseling provided by us is protected by law. Unless you grant us permission to do so in writing, therapists and office personnel will neither inform anyone that you are receiving therapy, nor will therapists disclose the content of any session. The only circumstances under which such professional confidentiality may be broken is if one or more of the following conditions apply: If you pose a serious physical danger to yourself or to another person. If you disclose that you or another person has physically or sexually abused or molested a child, an incompetent or disabled person. If you disclose that a child, an incompetent or a disabled person is suffering because of neglect. If abuse or neglect is disclosed under the conditions given above, we are mandated by Colorado law to report such information to an appropriate state agency. If I elect to use my health insurance plan to assist in the payment of treatment then I understand that my insurance carrier and the National Information Center will have access to my diagnosis code and other pertinent data needed for claim processing. FINANCIAL AGREEMENT AND AUTHORIZATION FOR TREATMENT I have been informed of and read the preceding information and agree to it. I authorize treatment of the person named below and agree to pay all fees as stated above.

___________________________________ Signature of Client or Legal Guardian

___________________________________ Signature of Spouse (when in joint therapy)

___________________________________ Date

___________________________________ Date

___________________________________ Signature of Counselor

___________________________________ Date

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Confidential Client Information
Personal Information: Today’s Date: ____________ Last Name: __________________________ First __________________________ Middle Initial _______ Address: ______________________________________________________________________________ City: _______________________________ State______________________Zip _____________________ Occupation _________________________________ Highest Level of Education ____________________ Home Phone: ________________ Work Phone: __________________ Cell Phone ___________________ But Prefer you contact me at _____________or Email Address: __________________________________ Birth Date: ___________________ Age: ___________ Sex: Male ______ Female _______

Marital Status: Single ____ Married ____ Widowed ____ Divorced ____ Separated ____ Engaged ____ How long ___________ If married, spouse’s name: ________________ Wedding Date ________________ Is your spouse supportive of you seeking counseling? ___________________________________________ Do you have children? ________ Ages: _____________________________________________________ In case of emergency please notify: _________________________________________________________ Medical History: Are you currently under medical care? ____ If yes, please indicate reason __________________________ ______________________________________________________________________________________ Physician’s Name _____________________________ Phone: __________________________________ Do you (or spouse if marriage counseling) take any prescription medications? _____ If yes, what are they? ______________________________________________________________________________________ Other significant medical history ___________________________________________________________ ______________________________________________________________________________________ Counseling History: Have you previously seen a counselor/therapist/psychologist/psychiatrist? __________________________ Name/Date/Location _____________________________________________________________________ When was your last appointment with any of the above? ________________________________________ Have you ever attempted suicide? _____ Have any family members attempted suicide? ________________ In your own words, write why you are seeking counseling: ______________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ How long have these concerns been causing you distress? _______________________________________ By whom were you referred to this counseling center? __________________________________________ How do you hope counseling will help? ______________________________________________________ ______________________________________________________________________________________ Is there anything else you feel that is important for the counselor to know: __________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
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Front Range Counseling Center, Inc.

COLORADO NOTICE FORM OF HIPAA LEGISLATION
Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE

REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations Your counselor may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions: ―PHI‖ refers to information in your health record that could identify you. ―Treatment, Payment, and Health Care Operations‖ – Treatment is when your counselor provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when your counselor consults with another health care provider, such as your family physician or another psychotherapist. – Payment is when you obtain reimbursement for your healthcare. Examples are if your counselor discloses your PHI to your health insurer for reimbursement for health care. – Health Care Operations are activities that relate to the performance and operation of your counselor’s practice. Examples of health care operations are quality assessment and improvement

activities, business related matters such as audits, administrative services, case management, and care coordination.
―Use‖ applies only to activities within your counselor’s [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. ―Disclosure‖ applies to activities outside of your counselor’s [office, clinic, practice group, etc.] such as releasing, transferring, or providing access to information about you to other parties. II. Uses and Disclosures Requiring Authorization Your counselor may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An ―authorization‖ is written permission above and beyond the general consent that permits only specific disclosures. In those instances when your counselor is asked for information for purposes outside of treatment, payment or health care operations, your counselor will obtain an authorization from you before releasing this information. Your counselor will also need to obtain an authorization before releasing your Psychotherapy Notes. ―Psychotherapy Notes‖ are notes your counselor has made about your conversation during a private, group, joint, or family counseling session, which your counselor has kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) your counselor has relied

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COLORADO NOTICE FORM OF HIPAA LEGISLATION
on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy. III. Uses and Disclosures with Neither Consent nor Authorization Your counselor may use or disclose PHI without your consent or authorization in the following circumstances: Child Abuse – If your counselor has reasonable cause to know or suspect that a child has been subjected to abuse or neglect, your counselor must immediately report this to the appropriate authorities. Adult and Domestic Abuse – If your counselor has reasonable cause to believe that an at-risk adult has been mistreated, self-neglected, or financially exploited and is at imminent risk of mistreatment, selfneglect, or financial exploitation, then your counselor must report this belief to the appropriate authorities. Health Oversight Activities – If the Grievance Board for Unlicensed Psychotherapists or an authorized professional review committee is reviewing my services, your counselor may disclose PHI to that board or committee. Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or the records thereof, such information is privileged under state law, and your counselor will not release information without your written authorization or a court order. The privileged does not apply when you are being evaluated or a third party or where the evaluation is court ordered. You will be informed in advance if this is the case. Serious Threat to Health or Safety – If you communicate to your counselor a serious threat of imminent physical violence against a specific person or persons, your counselor has a duty to notify any person or persons specifically threatened, as well as a duty to notify an appropriate law enforcement agency or by taking other appropriate action. If your counselor believes that you are at imminent risk of inflicting serious harm on yourself, your counselor may disclose information necessary to protect you. In either case, your counselor may disclose information in order to initiate hospitalization. Worker’s Compensation – your counselor may disclose PHI as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provided benefits for work-related injuries or illness without regard to fault. IV. Patient’s Rights and Psychotherapist’s Duties Patient’s Rights: Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information regarding you. However, your counselor is not required to agree to a restriction you request. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing your counselor. On your request, your counselor will send your bills to another address.)

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Front Range Counseling Center, Inc.

COLORADO NOTICE FORM OF HIPAA LEGISLATION
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in your counselor’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Your counselor may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, your counselor will discuss with you the details of the request and denial process. Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your counselor may deny your request. On your request, your counselor will discuss with you the details of the amendment process. Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, your counselor will discuss with you the details of the accounting process. Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically. Psychotherapist’s Duties: Your counselor is required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. Your counselor reserves the right to change the privacy policies and practices described in this notice. Unless your counselor notifies you of such changes, however, your counselor is required to abide by the terms currently in effect. If FRCC revises its policies and procedures, your counselor will notify you by mail. V. Questions and Complaints If you have questions about this notice, disagree with a decision your counselor makes about access to your records, or have other concerns about your privacy rights, you are encouraged to discuss this with your counselor prior to your first session. If you believe that your privacy rights have been violated and wish to file a complaint with Front Range Counselor Center, Inc., you may send your written complaint to: Front Range Counseling Center, Inc. Attention: Records 6901 S. Pierce Street, Suite 235 Littleton, CO 80128 You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.

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COLORADO NOTICE FORM OF HIPAA LEGISLATION
VI. Effective Date, Restrictions, and Changes to Privacy Policy This notice will go into effect on January 26, 2009. FRCC reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that your counselor maintains. FRCC will provide you with a revised notice by mail within ten business days prior to changes. VII. Client Signature I have read the above terms and understand them as stated. I have been informed of my therapist’s policies and practices to protect the privacy of my health information.

___________________________________ Signature of Client or Legal Guardian

___________________________________ Signature of Spouse (when in joint therapy)

___________________________________ Date

___________________________________ Date

___________________________________ Signature of Counselor

___________________________________ Date

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