Nancy Goodman, LCSW
12157 W. Cedar Dr. Suite 200
Lakewood, CO 80228
303-916-6929 * www.aparentconnection.com
email@example.com * License #992896
Practices and Policies
Welcome to my counseling and psychotherapy practice. I look forward to working with you. Following is some information about my policies and procedures.
If an appointment is cancelled outside 24 hours, you will not be responsible for payment. If an appointment is cancelled inside 24 hours, you will be responsible for the full fee.
It may become useful during the course of treatment to communicate by email, text message (e.g. “SMS”) or other electronic methods of communication. Be informed that these methods, in their typical form, are not confidential means of communication. If you use these methods to communicate with me, there is a reasonable chance that a third party may be able to intercept and eavesdrop on those messages. The kinds of parties that may intercept these messages include, but are not limited to: People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages; Your employer, if you use your work email to communicate with me; Third parties on the Internet such as server administrators and others who monitor Internet traffic. If there are people in your life that you don’t want accessing these communications, please talk with me about ways to keep your communications safe and confidential.
Couples and Families
Whenever more than one related person is seen by me individually or in a couple, issues around confidentiality and conflicts of interest must be discussed. Related individuals must be fully informed about the planned work. And in order to protect my role as therapist, each person must agree to respect the confidentiality of other family members. In addition, each person must agree to not involve me in litigation with the other.
I charge $120/50 minutes and $180/80 minutes. I ask that clients bring the full fee with them to each session unless we make other arrangements. Calls for purposes other than information or scheduling will be charged in quarter-hour increments of the full fee (e.g., 15 minutes = 25% of full fee If you wish to use insurance, it is up to you to determine whether any reimbursement is possible prior to beginning therapy. I will assist in obtaining insurance reimbursement by providing the requisite paperwork after a release of information is signed. Payment for returned checks and penalty fees are due upon notification. After fees are three months overdue, and you have been notified of same, I may engage the services of a collection agency. If payment becomes a problem for you, you and I should discuss that situation and make arrangements.
Health Care Benefits
In the event that you choose to use your health care benefits and my services are reimbursable under your insurance plan, you will have to give me written authorization to release required information. My policy is to provide the least amount of information necessary for the purpose of authorizing benefits. However, I can no longer be in control of the storage or access to your confidential information when it is given to a third party. The insurance company will determine benefit coverage and the kind of service for which they will reimburse.
If you are involved in divorce or custody litigation, please understand that my role as a therapist is not to make recommendations for
the court concerning parenting or custody issues, nor to testify in court concerning an opinion or issue involved in the litigation. By signing this disclosure statement you agree to not call me as a witness in any such litigation. Only court appointed evaluators can make recommendations to the court on disputed issues concerning parental responsibilities and parenting plans. Information discussed in therapy is meant for your exclusive use in healing and growth. Evaluations to be used for legal purposes should be obtained from a non-treating professional independent of the therapy.
Records may include identifying information, dates and types of sessions, an assessment and diagnosis, a treatment plan, progress notes or treatment summaries, any reports or correspondence, consultations, or collateral contacts made and informed consent disclosures. My private psychotherapy notes are kept separate and are not a part of the record. These psychotherapy notes are further protected from subpoena and unauthorized access by HIPAA. Your records will be stored safely with attention to your privacy for at least 7 years as required by Colorado statute. Your records are protected by Colorado statute, HIPAA regulations, and professional ethics. Records can only be released with your written permission and direction. It is my policy to not release an entire record, even with your authorization. Instead, I may summarize the content related to the request. Colorado Statute, CRS 25.1.803 limits release to a summary after termination. You will be granted reasonable access to your record, but no copy of the record. If you choose to read your record, it is my policy to be present in order to respond to any questions or confusion you may have about the recordings. You may request, in writing, an amendment or addition to your record. If you were seen in couple or family sessions, all adults present will have to sign for the release of any record or information gathered from our joint work.
Telephone & Virtual Therapy
In certain circumstances, I provide therapy on the phone or via Zoom for 50- or 80- minute sessions. Circumstances that might warrant tele-therapy include but aren’t limited to: Client transportation issues, client (or client’s child’s) illness, temporary scheduling conflicts between client and therapist and the global pandemic. Potential risks of tele-therapy sessions are: bad connection, poor reception, dropped calls, distractions in the client’s location, the decrease of body language and facial expressions to inform the communication. At the beginning of each tele-therapy session, we will decide what to do if the connection is lost.
Consent to Treatment
I am entering into this therapy contract with full understanding, participation, and consent. I understand I have a right to a second opinion from another mental health professional at any time and to register a legitimate concern with an appropriate agency as indicated on the Client’s rights form.