EVOX Forms

EVOX Disclosure Statement

Ashley D. Swanson, NLC LPC

Mailing Address:

4155 E. Jewell Ave. Suite #801

Denver, CO 80222

Licensure:

Registered Psychotherapist (NLC) - CO - #0107927 - Colorado Department of Regulatory Agencies

Licensed Professional Counselor (LPC) – KS - #3105 – Kansas Behavioral Sciences Regulatory Board

Degrees:

Masters Degree (MS)– Counseling Psychology, University of Kansas

Bachelors Degree (BA) – Psychology, University of Richmond, Virginia

Certifications/Trainings:

2017 Certified ZYTO EVOX Practitioner

Client Rights:

A. The Colorado Department of Regulatory Agencies (DORA) has the general responsibility of regulating the practice of licensed psychologists, licensed social workers, licensed professional counselors, licensed marriage and family therapists, certified school psychologists, and unlicensed individuals who practice psychotherapy. The agency within the department that has responsibility specifically for licensed and unlicensed psychotherapists is the State Grievances Board: 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.

B. You are entitled to inquire about and receive additional information about our methods of therapy, the techniques that are used, the duration of your therapy (if known), and the fee structure.

C. You can seek a second opinion from another therapist or terminate the counseling relationship at any time. As termination is a very important process, it is strongly encouraged to discuss this decision with your therapist before terminating.

D. Generally speaking, the information provided by a client during therapy sessions is legally confidential. If the therapist is a certified school psychologist, a licensed clinical social worker, a licensed marriage and family therapist, a licensed professional counselor, a licensed psychologist, or an unlicensed psychotherapist practicing under the supervision of a licensed psychotherapist, the therapist cannot be forced to disclose information to any person or entity. Disclosure requires written consent from the client.

E. Information disclosed to a licensed clinical social worker, a licensed marriage and family therapist, a licensed professional counselor, a licensed psychologist, is privileged communication and cannot be disclosed in any court of competent jurisdiction in the State of Colorado without the consent of the person to whom the testimony sought relates.

There are exceptions to this confidentiality, some of which are listed in section 12-43-218 and in the Notice of Privacy Rights you were provided as follows:

Harm to (or intent to harm) self or others;
Neglect and/or abuse of children or suspected neglect and/or abuse of children;
Neglect and/or abuse or suspected neglect and/or abuse of the elderly or others unable to care for themselves;
If court-ordered in a criminal or delinquency proceeding.

▪ Please note: if circumstances require the disclosure of confidential information, only essential information is revealed.

▪ Additionally, be aware that, except in the case of information given to a licensed psychologist, legal confidentiality does not apply in a criminal or delinquency proceeding.

F. 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. If sexual intimacy occurs it should be reported to the Department of Regulatory Agencies, Mental Health Section, at: Department of Regulatory Agencies, Mental Health Section, 1560 Broadway, Suite 1350, Denver, CO 80202 or (303) 894.7766.

G. You have the right to a non-discriminatory counseling experience; this includes discrimination on the basis of race, sexual orientation, gender identification, age, religion, size, and physical ability. Please feel free to discuss this further with your therapist, if you have any questions or concerns.

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 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.

A Licensed Social Worker must hold a masters 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 bachelors 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 masters degree and meet the CAC III requirements.

A Registered Psychotherapist is registered with the State Board of Registered Psychotherapists, 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

As a Psychotherapy Client, I understand that:

I consent to evaluation and mental health treatment for myself. I am aware that care and treatment is not an exact science and acknowledge that no guarantees have been made to me as to the result of treatment.

I understand that Ashley Swanson, NLC, LPC, generally provides non-emergency psychotherapeutic services by scheduled appointment. If she believes that my psychotherapeutic issues are outside of her level of competence and/or training, or outside her scope of practice, she is legally required to refer, consult, or terminate the counseling relationship.

EVOX therapy is NOT intended for crisis situations. If I am experiencing a crisis, or an emergency does arise, I will go to the nearest emergency room or call 911 or a Crisis Hotline to ensure immediate care.

I understand that there may be times when my psychotherapist may need to consult with a colleague or other trained professional (ie: an attorney, a licensed psychologist, a psychiatrist, etc.) about issues that arise during my therapy. I understand that my confidentiality is still thoroughly protected during this consultation by my therapist and the professional consulted. Signing this disclosure statement gives my psychotherapist permission to consult as needed to provide professional services to me as a client.

Sessions are $135.00 per session for an initial 90 minute Evox session

$95.00 per session for a 60 minute individual EVOX session.

Consultations and presentations are also available to organizations and groups, please inquire for more information.

Ashley Swanson, NLC, LPC has a 24 hour cancellation policy. Therefore, if I need to cancel an appointment, I must call to cancel at least 24 hours before the scheduled appointment, or I will be charged $65 for a session. Exceptions are made only for true emergencies.

Payment is due in full the day of service. Acacia Whole Health does not bill Health Insurance Companies or write letters for Health Flex Plans.

I understand that I am legally responsible for payment for my psychotherapy services.

If a collection agency is needed for non-payment, my right to confidentiality is automatically waived. I further understand that I must repay the full amount of the service, as well as any bank fees or other relevant costs to my therapist for bounced checks.

If there are any additional questions or concerns at any time, or if any additional information or resources are needed, it is my right and responsibility to have that discussion with the therapist.

Liability Release/Hold Harmless Agreement:

I understand that, except in the event of wanton and willful negligence, I am responsible for death, bodily injury, or property damage, which I or my child or legal ward should sustain during treatment with Ashley Swanson, NLC, LPC. I am also responsible for any attendance or time that I or my child or legal ward shall lose from employment or school or other activity and for medical expenses or any other expenses incurred because of such bodily injury or property damage. I will defend and hold Ashley Swanson and Acacia Whole Health harmless against any and all damages, liabilities, losses, claims, demands, causes of action, judgments, costs, penalties, and expenses, including reasonable attorneys’ fees, arising from any of my, or my child’s or legal ward’s, negligent or intentional acts or failures to act.

Note: The Colorado Department of Regulatory Agencies (1560 Broadway, Suite 1350, Denver, CO 80202 or (303) 894.7766) has the general responsibility of regulating the practice of licensed and unlicensed psychotherapists.

I have read the preceding information, it has also been provided verbally, and I understand my rights as a client/patient.