Disclosure

Colorado Mandatory Disclosure Statement

This statement is being provided to you so that you are aware of your rights as a psychotherapy client. Please read this and discuss any questions or concerns you have before signing it. After your reading and full comprehension of the material, please initial at the bottom of each page and sign at the end of the document designating your informed consent of, and agreement to engage in psychotherapy services with Laura Giles, LLC. This document will be placed in your file.

Laura Giles, LCSW

3064 W River Road Suite F

Goochland, VA 23063

www.lauragiles.net

804.307.9369

As a practicing therapist, I am committed to providing quality, time-effective treatment to individuals and couples regardless of age, race, gender identity, sexual orientation or religious affiliation. 

Degrees and Credentials

License # Virginia 0904006888; Colorado CSW.09931073; Indiana 34011458A

MWS, Master of Social Work from Norfolk State University, 2003

B.S. in Human Services Counseling from Old Dominion University, 2001

Colorado State Law requires that I provide you with the following information:

1. The practice of licensed or registered persons in the field of psychotherapy is regulated by the Colorado Department of Regulatory Agencies through the Mental Health Licensing Section of the Division of Professions and Occupations. The Board of Registered Psychotherapists can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.

1. As to the regulatory requirements applicable to mental health professionals, unlicensed psychotherapist is a psychotherapist listed in the State’s database and 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. A Certified Addiction Counselor I (CAC I) must be a high school graduate, complete required training hours and 1,000 hours of supervised experience. A Certified Addiction Counselor II (CAC II) must complete additional required training hours and 2,000 hours of supervised experience. A Certified Addiction Counselor III (CAC III) must have a bachelor’s degree in behavioral health, 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 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 Licensed Professional Counselor, Licensed Clinical Social Worker, and a Licensed Marriage and Family Therapist must hold a master’s degree in their profession and have two years of post- master’s supervision. A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision.

3. 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 also have the right to seek a second opinion from another therapist or terminate therapy at any time.

4. In a professional relationship, such as psychotherapy, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant or certificate holder.

5. 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 (see below), some of which are listed in section 12-43-218 of the Colorado Revised Statutes and the HIPAA Notice of Privacy Rights, as well as other exceptions in Colorado and Federal law.

Exceptions to therapist-client confidentiality include:

a. I am required to initiate a mental health evaluation if a client is imminently dangerous to self or to others, or gravely disabled, as a result of a mental disorder;

b. I am required to report any suspected incident of child abuse or neglect to law enforcement;

c. I am required to report any threat of imminent physical harm by a client to law enforcement and to the person(s) threatened;

d. I am required to report if you disclose or I observe that a child, or disabled person, or an at-risk elder person is suffering or at imminent risk of abuse, neglect or exploitation;

e. I am required to report any suspected threat to national security to federal officials;

f. I may be required by Court Order to disclose treatment information.

If abuse or neglect is disclosed under the conditions given above, I am mandated by Colorado law to report such information to an appropriate state agency. If feasible, you will be informed accordingly.

Additionally, it is my policy to request a Welfare Check through local law enforcement whenever I am concerned about a client’s safety. In doing so, I may disclose to law enforcement officers information regarding my concerns. By signing this document, you consent to this practice should it become necessary.

6. Under Colorado law, C.R.S. § 14-10-123.8, parents have the right to access mental health treatment information concerning their minor children, unless the court has restricted access to such information. If you request treatment information from me, I may provide you with a treatment summary, in compliance with Colorado law and HIPPA Standards.

Methods of Therapy:

I use a combination of therapeutic modalities that include but are not limited to: Internal Family Systems, Dialectic Behavioral therapy, Polyvagal theory, Somatic Experiencing, The Fairy Tale Model, and Energy Psychology.

There are no guarantees to the outcome of therapy or the length of time required. Successful sessions often depend on the therapist – client relationship and the committed effort of both parties. You have the right to know what other treatment options are available and the possible effectiveness of those alternatives. You may at any time seek a second opinion from another clinician and/or terminate the counseling process. It is your responsibility to ensure that I am informed if you are working with more than one counselor.

I will not record our sessions (audio or video) without your written consent; and expect that you will not record a conversation in any manner without my written consent.

Supervision:

As part of my commitment to providing quality care, I regularly participate in direct individual supervision with licensed professional counselors and/or licensed psychologists and, as deemed necessary, seek peer consultation with a colleague on your case. Supervisors and colleagues are subject to the same confidentiality laws as described above.

Communications:

I use standard business communications equipment in my private practice to communicate with clients, colleagues, third-party vendors and other professionals. This equipment includes cellular telephones, email, and faxes. I am the only person with authorized access to all equipment. However, it is understood that communication via these methods is not encrypted. To maintain client confidentiality, please communicate via the HIPAA compliant client portal.

Crisis/Emergency:

Laura Giles, LLC is not able to handle 24 hour contact and/or emergencies. Any emergency situation that you experience, should be directed to the appropriate emergency personnel such as the services provided by calling 911, the police, the fire department, a hospital, or your county mental health department.

Fee Structure:

Counseling fees are $165.00 per 50-minute session.

Payment:

Full payment for counseling or testing services is due at the time of service. Please have an unexpired credit card on file. Your account will be debited at the end of each business day and must be paid in full before your next appointment.

Out-of-Network Insurance:

If your insurance is out-of-network, you will be responsible for the full fee of your session. You will receive a statement that can be used to file the claim yourself. 

Cancellations/Missed Appointments:

If you must miss an appointment, please notify me as soon as possible (but at least 24 hours in advance) to avoid a missed appointment fee of $50. 

Divorce, Custody Litigation and other Court Proceedings:

I will not voluntarily represent any client in any litigation of any kind, including expert witness or witness of fact, divorce cases, child custody issues, criminal cases, or any other type of court proceeding. By signing this document, you agree not to subpoena me to court for testimony or for disclosure of treatment information; and you agree not to request that I write any reports to the court or to your attorney, making recommendations concerning custody issues or parenting time. The court can appoint professionals, who have no prior relationship with family members, to conduct an investigation or evaluation and to make recommendations to the court concerning parental responsibilities or parenting time in the best interests of the children. I am not the best person to fulfill that function. Due to the preparation time required for court involvement and the potential for missed counseling income in my private practice, the charge for any court appearances, including preparation and transportation, is $250 per hour.

Maintenance of Records:

Any person who alleges that a mental health professional has violated the licensing laws related to the maintenance of records of a client 18 years of age or older, must file a complaint or other notice with the licensing board within seven years after the person discovered or reasonably should have discovered the violation. Pursuant to law, this practice will maintain records for a period of seven years commencing on the date of termination of services or on the date of last contact with the client, whichever is later. When the client is a child, the records must be retained for a period of seven years commencing either upon the last day of treatment or when the child reaches 18 years of age, whichever comes later, but in no event, shall records be kept for more than 12 years.

Cessation or Termination of the Clinical Relationship:

Psychologists and Therapists strive to benefit those with whom they work and take care to do no harm. Competence is a cornerstone of ethics. A psychologist who is not competent is likely to cause harm. Clinical termination is the best way to avoid that harm.

I will chose to terminate the clinical relationship if it becomes reasonably clear that you the client no longer need the service, are not likely to benefit from the service, or are being harmed by continued service. Termination against your wishes does not constitute abandonment. 

I may chose cessation of services if I determine we are not a good therapeutic fit, if what you are going through requires more training than I currently possess, if you require specialized support or if we are not able to form a therapeutically effective relationship.

You have the right to terminate the clinical relationship at any time for any reason.

If you chose not to schedule with me for longer than 30 sequential days, your file will be closed and your space will be made available to someone else. I have always prioritized returning clients and try to make space for them; however, to give everyone quality service, this cannot be guaranteed due to time available. If my schedule is full, we will not be able to reenter the therapeutic relationship at that time. Should we begin meeting again the client must sign a new disclosure statement and agree to the current fee schedule and terms.

I have read the statements and understand my rights as a client or the client’s responsible party.