• Change Inc. New Client Intake Form

  • Demographic Information

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  • Confidentiality & Disclosure Notices

  • We are a professional corporation, co-owned by Philippe R. Marquis, M.A., L.P.C., and Joseph R. Fojut, M.A., L.P.C.  All other mental health professionals who provide services are employees of the corporation, contract employees, or interns and are subject to the guidelines of the corporation and the Department of Regulatory Agencies.  Philippe R. Marquis and Joseph R. Fojut are Licensed Professional Counselors and supervise all staff regardless of employment status.

    Philosophy

    Your decision to enter psychotherapy is an opportunity to turn a crisis into new understanding, a roadblock into a bridge to the future.  We hope that our professional relationship supports your progress by offering an atmosphere of safety, trust, and confidentiality.  We accept into our agency only clients who believe they have the capacity to resolve their own problems with our assistance.  We believe that as people become more accepting of themselves, they are more capable of finding happiness and contentment in their lives.  However, self-awareness and self-acceptance are goals that sometimes take a long time to achieve.  Some clients need only a few sessions to achieve these goals, whereas others may require months or even years of psychotherapy and/or psychological services.  As a client you are in complete control and may end our professional relationship at any time.  When psychotherapy is successful, you should feel that you are able to face life’s challenges in the future without our support or intervention.

     

    Mandatory Disclosure

    The practice of licensed and registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The Board of Licensed Professional Counselor Examiners and the Board of Registered Psychotherapists can be reached at 1560 Broadway, Suite 1350, Denver, CO, 80202, (303) 894-7800. The practice of licensed social workers is regulated by the Social Workers Examiners Board which can be reached at 1560 Broadway, Suite 1370, Denver, CO, 80202, (303) 894-7766. As to the regulatory requirements applicable to mental health professionals:

    ✓ Registered psychotherapist is a psychotherapist listed in the State's database and is authorized by law to practice psychotherapy in Colorado but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state.

    ✓ Certified Addiction Counselor I (CAC I) must be a high school graduate, complete required training hours and 1,000 hours of supervised experience.

    ✓ Certified Addiction Counselor II (CAC II) must complete additional required training hours and 2,000 hours of supervised experience.

    ✓ Certified Addiction Counselor III (CAC III) must have a bachelors degree in behavioral health, complete additional required training hours and 2,000 hours of supervised experience.

    ✓ Licensed Addiction Counselor must have a cliChange Incal masters degree and meet the CAC III requirements.

    ✓ Licensed Social Worker must hold a masters 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 the process of completing the required supervision for licensure.

    ✓ Licensed CliChange Incal Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a masters 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 board that licenses, registers, or certifies the licensee, registrant or certificate holder.

     

    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.

     
     
    Confidentiality                                                                                                         
    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, and the HIPAA Notice of Privacy Rights you were provided, as well as other exceptions in Colorado and Federal law. For example, mental health professionals are required to report suspected child abuse to authorities. If a legal exception arises during therapy, if feasible, you will be 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.  Some other examples are:

    • We are required by law to report suspected child abuse and/or neglect without an investigation to the proper authorities, who   may then investigate.

    • We may take some action without your consent if we deem you to be a serious harm to yourself or another.

    • If you file an official complaint or a lawsuit against one of our therapists, according to Colorado law, your right to confidentiality will be waived.

    • If you choose to use your health benefit plan, you will have to give consent for required confidential information to be given to your insurance company or managed care company for the purpose of determining eligibility for reimbursement.

     

    Fees        

    This time is reserved for you.  You are responsible for payment at the time of each session.  We must receive cancellation 24 hours before your scheduled appointment time; otherwise you will be charged for that session.  We do not accept personal checks as a form of payment. If we are unable to collect our agreed upon fee after 90 days when the service was provided, we may send your name and address to a collection agency or seek collection with a civil court action.  Should this occur, we will provide the collection agency or Court with your Name, Address, Phone Number, and any other directory information, including dates of service or any other information requested by the collection agency or Court deemed necessary to collect past due account. 

     

    Health Care Benefits

    In the event that you choose to use your health care benefits and our services are reimbursable under your insurance plan, you will have to give us consent to release required information.  Released confidential information may range from identifying information, diagnosis, and dates of sessions to a complete assessment with treatment goals and progress reports when your benefits fall under managed care.  We cannot be in control of the storage of confidential information nor 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.  We will discuss with you my recommendations for treatment, and you will decide how you want to proceed.

     

    Emergency Contacts 

    For immediate help, call 911 or go to your local Emergency Room.  You can also contact the Colorado Crisis Line at 1-844-493-8255. 

     

    Termination

    Termination will usually be agreed upon mutually, but you are free to terminate at any time.  However, in a few special circumstances the decision to discontinue treatment may be made, even though you wish to continue.  These circumstances may include, but are not limited to, a failure to meet the terms of the fee agreement, or a need for special services outside the area of our competency.  Should this occur, the reason for termination will be discussed with you, and you will be helped to make different plans for yourself, including a referral to a more appropriate resource (s).  Additionally, in the event a client discontinues contact with Change Inc for 30 days or longer, he/she will be considered discharged from treatment at Change Inc.

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  • Staff Disclosure Information

    Joseph R. Fojut, M.A. in Community Counseling from University of Northern Colorado, 2004; B.S.W. in Social Welfare from Criminal Justice from University of Wisconsin at Milwaukee, 1995; Licensed Professional Counselor (LPC #4689 issued in CO 6-26-2007), DVOMB Approved Clinical Supervisor and Provider;.

    Alina Galushko Mitchell, M.A. in Counseling Psychology & Counselor Education from University of Colorado Denver, 2010; B.S. in Psychology from Colorado State University, 2007; Licensed Professional Counselor (#0011207 issued in CO 10-01-2012); Licensed Addiction Counselor (#0000623 issued in CO 10-02-2015), DVOMB Approved Provider.

    Jordan Herselman, M.A. in Clinical Mental Health Counseling from Denver Seminary, 2016; Licensed Professional Counselor (#0015116 issued in CO 1-8-2019), DVOMB Approved Provider, Licensed Addictions Counselor, (#0001256 issued in CO 5-24-2019).

    Lydia Hoffmann, M.A. in Clinical Mental Health Counseling from Denver Seminary, 2018; Licensed Professional Counselor (#16962 issued in CO 3-21-2021), DVOMB Approved Provider, Licensed Addictions Counselor, (#2045 issued in CO 5-3-2022).

    Amanda N. Hua, MA, Colorado Christian University. EMDR, DVOMB Approved Provider, Licensed Professional Counselor (#16056 issued 2/11/2020).

    Philippe R. Marquis, M.A. in Community Counseling from University of Northern Colorado, 2001;B.S. in Human Services from Metropolitan State College, 1995; Licensed Professional Counselor (LPC #4429 issued in CO 8-25-2006), DVOMB Approved Provider; Licensed Addiction Counselor (#1025 issued in CO 5/16/2018).

    Jeremy Reichert, M.A. in Community Counseling from Colorado Christian University, 2011; Unlicensed Psychotherapist (#NLC.0012669 issued in CO 10/12/2010).

     

     

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