EVOX Disclosure Statement
Ashley D. Swanson, MS, NLC, LPC
4155 E. Jewell Ave. Suite #801
Denver, CO 80222
Registered Psychotherapist (NLC) - CO - #0107927 - Colorado Department of Regulatory Agencies
Licensed Professional Counselor (LPC) – KS - #3105 – Kansas Behavioral Sciences Regulatory Board
Masters Degree (MS)– Counseling Psychology, University of Kansas
Bachelors Degree (BA) – Psychology, University of Richmond, Virginia
2017 Certified ZYTO EVOX Practitioner
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:
▪ 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:
$85.00 per session for a 60 minute individual EVOX session.
Consultations and presentations are also available to organizations and groups, please inquire for more information.
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.
Welcome to Acacia Whole Health!
Please complete this information before your Initial EVOX appointment, so that we may serve you better. It takes approximately 15 minutes to complete.
See you soon,
Ashley Swanson, MS LPC, and the Staff at Acacia Whole Health