Disclosure Form and Clients Rights
a. Licensed Clinical Social Worker, Colorado License #992896
b. MSW, School of Social Work, University of Michigan, 1996
c. B.A., Psychology, University of California, Santa Cruz, 1992
d. EMDR Level II Training; December, 2003
e. Perinatal Mood Disorders Treatment Certification; October, 2002
2. The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Professions and Occupations. The Board of Social Worker Examiners can be reached at:
1560 Broadway, Suite 1350 Denver,
3. As to the regulatory requirements applicable to mental health professionals: 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.
4. You are entitled to receive information from your therapist about the methods of therapy, the techniques used, the duration of your therapy (if known), and the fee structure. You can seek a second opinion from another therapist or terminate therapy at any time.
5. In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant or certificate holder.
6. 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 and the Notice of Privacy Rights you were provided as well as other exceptions in Colorado and Federal law. Some of the exceptions include suspicions of child abuse, elder abuse or those deemed as vulnerable individuals; threats of self harm or harm to others; disclosed future illegal acts, and court subpoenas for records. All other disclosures of confidential information will be released only with a signed consent by the client. This includes acknowledgement to any third party that an individual is or is not a client of Nancy Goodman.
7. I am required to report any suspected threat to national security to federal officials; and I may be required to disclose treatment information when ordered by a court. You should be aware that provisions concerning disclosure of confidential communications shall not apply to any delinquency or criminal proceedings, except as provided under C.R.S. §13-90-107. It is possible that additional exceptions to confidentiality may apply. I will identify any exceptions to you if any such situation arises while the therapeutic relationship exists or after we have terminated the therapeutic relationship.
8. Supervision and peer consultation are part of every therapist’s growth. It may be that issues or specific considerations in your treatment may be discussed with other professionals. When this occurs, all identifying information (names, ages, residence) will be disguised to further protect your confidentiality.
9. The use of any electronic means of information exchange or storage cannot guarantee confidentiality. This includes any use of cell phones, voice mail, faxes, emails, Skype or other internet uses of video or audio messaging. Please see the “Communications Form” for more information and a place for you to authorize which type of communication you would like to use.
10. While there are occasions in which interactions between the therapist and client may occur outside the therapy session due to common interests or memberships, there will not be any confidentiality disclosed by the therapist, including acknowledgment that there is a client - therapist relationship.
11. I do not provide emergency care. If you are in need of emergency care that cannot wait 48 hours, please call your nearest emergency room or 911.
12. If I believe your psychotherapeutic issues are above my level of competence or outside of my scope of practice, I am legally required to refer, terminate or consult with other professionals in order to provide you with appropriate treatment.
13. There is no guarantee that psychotherapy will yield positive or intended results. Although every effort will be made to provide a positive and healing experience, every therapeutic experience is unique and varies from person to person. Results achieved in a therapeutic relationship with one person are not a guarantee of similar results with all clients.
I have read the preceding information and understand my rights as a client.