Informed Consent for Psychological Assessment and Treatment Services with Cierra Townsend, M.A., Ph.D. Candidate

Thank you for choosing Wolff Child Psychology, PLLC, a private practice owned by Dr. Brian Wolff, Ph.D. This document is intended to inform you of our policies, and to meet the legal requirements of the State of Colorado. If you have questions or concerns, please ask and we will try our best to give you all the information you need.

 

Cierra Townsend, M.A., is a Ph.D. candidate in the Child, Family, and School Psychology program at the University of Denver. She received her B.A in Psychology and Women’s Studies at George Washington University and her M.A. in Early Child Special Education from Mills College. Her graduate training focused on equitable assessment and treatment of children and adolescents with learning disorders, ADHD, Autism Spectrum Disorder, and mood and behavioral concerns. Cierra completed her advanced training at the Developmental Neuropsychology Clinic and her pre-doctoral internship at Denver Public Schools.

 

Cierra Townsend's work is supervised by Drs. Nikki Pond and Jessica Torres. Dr. Nikki Pond is a Licensed Clinical Psychologist. She received her M.Ed. in Prevention Science and Practice from the Harvard Graduate School of Education and her M.A. and Psy.D. in Clinical Psychology from the University of Denver. She completed pre-doctoral training in assessment at National Jewish Health, as well as training in therapy and assessment for children with complex trauma, depression, and anxiety at Denver Children's Home. As a pre-doctoral intern, she completed an APA-accredited one-year internship training program in child and adolescent psychology at Denver Children's Home through the DU Graduate School of Professional Psychology Internship Consortium. Her license is #5344.

 

Dr. Jessica Torres is a Licensed Clinical Psychologist. She received her M.A. and Ph.D. in Child Clinical Psychology from the University of Denver. She completed pre-doctoral training in assessment, therapy, pediatric primary care, postpartum depression, and infant development through the Department of Psychiatry and Behavioral Sciences at Children’s Hospital of Colorado in Aurora. As a pre-doctoral intern, she completed an American Psychological Association accredited internship training program in child clinical and pediatric psychology through the Children’s Hospital of Orange County Pediatric Psychology Department in Orange, California. She then completed her postdoctoral training with Wolff Child Psychology and has served as a clinical supervisor for the University of Denver’s clinical child psychology doctoral program. Her license is #4828.

 

Client Rights

 

* 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 Psychologist Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800. As to the regulatory requirements applicable to mental health professionals: A 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. A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision. A Licensed Social Worker must hold a Master’s degree in social work. A 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. A Certified Addiction Counselor I (CAC I) must be a high school graduate, and complete required training hours and 1000 hours of supervised experience. A CAC II must complete additional required training hours and 2,000 hours of supervised experience. A CAC III must have a Bachelor’s degree in behavioral health, and complete additional required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical Master’s degree and meet the CAC III requirements. A Registered Psychotherapist is registered with the State Board of Registered Psychotherapists, is not licensed or certified, and no degree, training or experience is required.

 

* 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.

 

* 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.

 

* The information provided by and to you as a client during assessment and therapy sessions is legally confidential and generally cannot be released without the client’s consent. There are exceptions to this confidentiality, which are listed in the Notice of Privacy Practices you were provided. For instance, if we are directed by a judge in a court of law to reveal information, then we must do so. Additionally, if you provide us with information about child abuse or neglect, abuse or neglect of the elderly, or abuse or neglect of a compromised adult, we must report that information immediately. If you tell us that you intend to harm someone else or yourself, we are required by law to reveal that information to the authorities and to the individual who may be harmed. In addition, we are required to work with you closely to preserve your safety. If a legal exception arises during therapy, if feasible, you will be informed accordingly.

 

* Certain functions of psychological testing, including collecting background and medical history, administering and scoring of psychological, social, behavioral, personality and neuropsychological measures and test interpretation, may be performed by a psychometrist under the supervision of Brian Wolff, Ph.D.

 

* You acknowledge, and by signing this form, agree that neither you nor the therapist will record (audio or video) any sessions without the prior mutual written consent of the therapist and client.

 

*You acknowledge and, by signing this form, agree that only a client's parents/caregivers can participate in sessions. This includes all types of sessions, such as, but not limited to, parent interviews, testing sessions, parent, child, or family therapy sessions, and evaluation feedback sessions. If you would like a third party to participate in a session, you must make the request in writing to the clinician. We will make the determination as to whether to approve the request, though know that approvals will be exceptionally rare and only granted when deemed clinically necessary by our team.

 

* Every Psychologist engaged in the practice of psychology as defined in C.R.S.§ 12-43-303 shall create and maintain records on each of his/her psychology clients. The Psychologist shall retain a record on each psychology client for a period of seven (7) years commencing on the date of termination of psychology services or on the date of last contact with the client, whichever is later.

 

How to reach Cierra Townsend:

 

You can reach me by calling my confidential phone line and voicemail at (303) 500-3407 or e-mailing me at cierra@wolffchildpsychology.com. Because I do not provide an emergency response system, I may not return your call promptly. On weekdays, I usually check my voicemail at least twice per day (i.e., in the morning and before the end of the business day On the weekends and on holidays, I check my voicemail at least once per day. I do not carry a pager or work cell phone.

 

E-mail is an acceptable form of communication with me; however, as with any form of communication, I cannot completely ensure its confidentiality. You should not email me with urgent concerns or to tell me about self-injurious thoughts or actions. Rather, you should call 911 or contact your nearest emergency room if you are in imminent danger of hurting yourself or someone else. If there is time for you to safely leave a message on my voicemail indicating you are in a state of emergency after you call 911 or go to an emergency room, please do that as well. You may also contact 1-800-273-TALK for immediate 24-hour services if you are thinking of hurting or killing yourself.

 

Clinical services provided by Wolff Child Psychology are not intended for use in any legal matter, including but not limited to child custody hearings, parental responsibility evaluations, and other legal matters. If you become involved in a legal matter during or after receiving services from Wolff Child Psychology, you agree to pay, at the legal matter hourly rate disclosed on the fee information form(s), for all time spent by a Wolff Child Psychology therapist on the legal matter. Such work may include, but is not limited to, responding to subpoenas, preparation related to the legal matter, phone calls, time to travel to and from hearings or depositions, time testifying, time spent waiting to be called for testimony, and any other time spent by Wolff Child Psychology related to the legal matter.

Collaborating on treatment is essential. Please keep me informed in terms of what you feel does or does not work for you in our sessions. Please give me feedback about anything about our work together that causes you distress or makes you feel uncomfortable. You are welcome and encouraged to ask questions about my theories and practices of psychotherapy, any of my policies, your bill, or any other concerns that arise. The better informed you are, the more effective our work together will be!

I have read the preceding information, it has also been provided verbally, and I understand my rights as a client or as the client’s responsible party. I have received a copy of this form for my own records.