Amy Sutton, MA, NCC
1720 Jet Stream Drive, Suite 203
Colorado Springs, CO 80921
(719) 494-5781
Disclosure Statement
Qualifications:
I hold a Master of Arts degree in Community Counseling from the University of Northern Colorado and a Bachelor of Arts degree in Psychology from the University of San Diego. I am currently supervised by Barry D. Ham, Ph.D, LMFT. I also consult with a number of licensed and qualified mental health professionals as the need arises.
Nature of Counseling:
I view counseling as a partnership that involves active, ongoing work. Instead of adhering strictly to one approach, I take into consideration the uniqueness and individuality of the client. Relevant therapeutic methods are adapted and integrated to create a holistic treatment plan that best serves the client's needs. Throughout our sessions, I am committed to supporting, challenging, encouraging, and empowering you. Please note that it is impossible to guarantee any specific results regarding your counseling goals, but together we will work to achieve the best possible results for you.
Regulations for Counselors:
The Colorado Department of Regulatory Agencies has the general responsibility of regulating the various professions in the field of counseling. The agency within the department that is specifically responsible for licensed and unlicensed psychotherapists can be reached at
Department of Regulatory Agencies
Mental Health Section
1560 Broadway, Suite 1350
Denver, Colorado 80202
(303) 894-7766
www.dora.state.co.us
Client's Rights and Important Information about Confidentiality:
You are entitled to receive information from me about my methods of therapy, techniques I employ, the duration of your therapy (if I can determine it). My fee is $85.00 per fifty minute session. You will be asked to make the payment at the beginning of each session. A standard $25 fee will be charged for any checks returned due to insufficient funds. Any phone conversation lasting more than 15 minutes will be billed at a prorated fee per my usual session rate. The fee for other professional services you request will be discussed if and when they arise.
You can seek a second opinion from another therapist or terminate therapy at any time.
Dual Relationship:
Although our sessions may be very intimate psychologically, it is important for you to realize that we have a professional relationship rather than a personal one. Our contact will be limited to the paid sessions you have with me. This is a requirement of the ethical guidelines for Licensed Professional Counselors and is in your best interest. You will be best served if our relationship stays strictly professional and if our sessions concentrate exclusively on your concerns. You will learn a great deal about me as we work together during our counseling experience. However, it is important for you to remember that you are experiencing me only in my professional role.
Colorado law requires me to inform you that in our professional relationship physical intimacy is never appropriate and should be reported to the Grievance Board at the following address: The Department of Regulatory Agencies, Mental Health Section at the address and telephone number indicated above.
Confidentiality:
The information provided by you, the client, and from me the therapist is generally legally confidential and I cannot be forced to disclose in any court of competent jurisdiction in the State of Colorado without the consent of the person to whom the testimony sought relates. The exceptions to the general rule of legal confidentiality are listed in the Colorado statutes (C.R.S. 12-43-218). Please be aware that provisions concerning disclosure of confidential communications shall not apply to any delinquency or criminal proceedings, except as provided in section 13-90-107 C.R.S.
Exceptions to Confidentiality:
1. Any evidence or disclosure by the client of perpetrating child abuse (past or present) must be reported to legal authorities.
2. Any evidence or disclosure by the client of mistreatment of an at-risk adult will be reported to legal authorities.
3. If an individual intends to take harmful, dangerous or criminal actions against another human being or against him/herself it is the therapist's duty to report such action or intent to medical and legal authorities. If in the clinical judgment of the therapist it is determined that you are a danger to yourself or someone else, by signing the consent you authorize this therapist to contact either the persons listed as your emergency contacts, or someone else to provide assistance through this crisis situation. This would include, at the therapist's discretion, contacting an intended victim. By law your consent is not necessary.
4. Sexual improprieties by a former therapist are a criminal offense and must be reported.
5. Certain court orders/actions such as custody cases, malpractice actions, etc. may legally require disclosure of certain material in our sessions.
6. Collection of fees may require disclosure that you have been in a counseling process.
7. If the client expressly consents or directs the therapist in writing to share information with another person.
8. Consultation and supervision with other professionals to aid in your treatment process.
Records:
All communications, including those from my supervisor, become part of your clinical record. I will provide at your written request a treatment summary unless I believe that to do so would be emotionally damaging. If that is the case, I will be happy to send the summary to another mental health professional who is working with you.
By signing below, you are indicating that you have read this document in its entirety and understand this statement, and/or that any questions you have about the statement have been answered to your satisfaction. You are further indicating that you are aware of counseling fees and billing practices, including the fact that you will be billed for any missed appointment that you do not cancel or reschedule at least 24 hours before your scheduled session.
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Client Signature Date
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Counselor Signature Date
By signing below, you are agreeing that the therapist will determine in her professional judgment what information is appropriate to share with the parents/legal guardians concerning treatment issues of a minor, and what information in the therapist's discretion will remain confidential between the minor and the therapist.
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Parent or Legal Guardian Date
(if client is under the age of 16)