IC & Policy Agreement
GUIDED REVOLUTION COUNSELING & ART THERAPY LLC
Meghan Montgomery, MAAT, LPC | LPCC
License #: 0017575 CO | 10093 CA
admin@guidedrevolution.com
720-258-6209
9878 W Belleview Ave Ste 2309 Littleton, CO 80123
DISCLOSURE STATEMENT, INFORMED CONSENT, AND POLICY AGREEMENT
General Information
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.
Your Rights as a Client
The practice of both licensed and unlicensed persons in the field of psychotherapy is regulated by the State of Colorado. 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 Licensed Professional Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.
You are entitled to receive information about the methods and techniques of therapy I use, duration of therapy (if known), fee structure, and my degrees, credentials and licenses. You may 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.
Records are maintained and will be destroyed in accordance with state and federal laws and regulations. Currently, Colorado law requires that I maintain your records for a period of seven (7) years commencing on the date of termination of services or the date of last contact with the client, whichever is later. When the client is a child, the records must be maintained 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. After this time, your records will be destroyed.
Levels of regulation of mental health professionals in Colorado include licensing (requires minimum education, experience, and examination qualifications), certification (requires minimum training, experience, and for certain levels, examination qualifications), and registration (does not require minimum education, experience, or training.) All levels of regulation require passing a jurisprudence take-home examination. This section provides information about the various types of mental health professionals and the required education, licensure, and supervised training that a person needs in order to practice in these professions.
A Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist (LMFT), and a Licensed Professional Counselor (LPC) must hold a masters degree in their profession and have two years of postmasters degree supervision.
A Licensed Psychologist must hold a doctorate degree in psychology and have one year of postdoctoral 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 Technician must be a high school graduate, complete required training hours, pass the National Certified Addiction Counselor Exam, Level I or an equivalent exam, and complete 1,000 hours of supervised experience. A Certified Addiction Specialist must have a bachelor’s degree or higher in substance abuse/behavioral health, complete additional required training hours, pass the National Certified Addiction Counselor Exam, Level II or an equivalent exam and complete 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical master’s or doctorate degree, pass the Master Addiction Counselor Exam or an equivalent exam, and complete 3,000 of supervised experience.
An Unlicensed Psychotherapist is registered with the State Board of Unlicensed Psychotherapists, is not licensed or certified, and no degree, training, or experience is required.
About the therapists Education/Training/Credentials
• Masters Degree in Counseling: Art Therapy - Adler University
• Licensed Professional Counselor - Colorado
• Licensed Clinical Professional Counselor - California
I received a Master of Arts in Counseling: Art Therapy from Adler School of Professional Psychology (University) in Chicago, Illinois, and a B.A. in Mental Health Psychology from Northeastern State University in Oklahoma. I have extensive experience working with teenagers and adults with a variety of diagnosis including sexual trauma, substance abuse, ADHD, gender and sexual identity, depression, and eating disorder treatment. I specialize in complex trauma, and working with individuals engaging in or in recovery from enduring and persistent eating disorders
Theoretical Perspective
I use an integrative approach with a strong emphasis on identity development, emotional regulation, and communication skills, combining Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, Acceptance and Commitment Therapy and Adlerian concepts to support the needs of the client. I often use Art Therapy to help access emotional bypassing and lean on holistic practices to augment coping skills and identity expression.
Location
Our sessions will be held virtually via SimplePractice, or, depending on appropriateness, on a public trail in Chatfield State Park (if participating in walk & talk therapy) for which additional consent forms will be required.
For Walk & Talk therapy, certain expectations may be required before this is considered, including evidence of medical stabilization and approval from medical providers regarding the safety and ability of the client to engage in recreational movement. Under this condition, when inclement weather is present, or a client is medically unstable, sessions will continue virtually through Simple Practice Telehealth portal.
**This consent will be updated if/when a physical office space is made available.**
Therapy is considered to take place when a client, who must be physically located in the state of Colorado at the time of session, is provided treatment by a clinician legally and currently licensed in the state of Colorado, in the United States of America. By signing this disclosure form, clients agree that all therapy is conducted under the rules and regulations of Colorado state law that are applicable to mental health professionals, regardless of your permanent or temporary location when any type of communication is made between us.
The Therapeutic Process
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot
promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.
Service, Fees and Payment
50 minute therapy sessions:
I offer therapy for individuals ages 14 and up. I charge $175 for a 50- minute individual session, or $195 for a 50-minute Couples/Family session unless otherwise agreed upon. If we meet for more than the regularly scheduled hour, I will charge accordingly for the additional time. I also charge this same hourly rate for other professional services, such as report writing, telephone calls, preparation of reports or treatment summaries, meeting with other professionals with your authorization, and time spent performing other services you request of me. Fees are subject to change periodically, and I will notify you in advance of any such fee increase.
If you become involved in legal proceedings, I charge $200 per hour for services related to your legal matter. You will be responsible for paying for any professional time I spend on your legal matter, even if the request comes from another party. Professional time spent on your legal matter includes, but is not limited to: attorney fees that I may incur in preparing for or complying with the requested legal services; testimony related matters such as case research, report writing, travel, depositions, actual testimony, cross examination, and courtroom waiting time. Please note that I will not provide evaluations or expert testimony in court, such services should be provided by an outside provider in order to preserve our therapy relationship.
You will be expected to pay for each session at the time it is held unless we have agreed otherwise in advance. If your account has not been paid for more than thirty (30) days and payment arrangements have not been agreed upon, your account will be considered past due and I have the option of using legal means to secure the payment. This may involve using a collection agency or filing a claim in small claims court. In collection situations, I will make all efforts to release the minimum information necessary to proceed with collections or a claim, which will include the client name, dates, times, and the nature of services, and the amount due. Before I engage a collection agency, I will provide you with written notice of my intent to do so, sent to your last address I have on record, and give you an opportunity to make payment arrangements.
I do not accept health insurance for mental health services and am not in network with any insurance provider. I am not a Medicaid provider. If you have Medicaid coverage that includes mental health services, I am not able to offer mental health services to you.
Cancellations and No-Show Policy
Since I have reserved your appointment time exclusively for you, it is my policy to receive at least a 48-hour cancellation notice or you will be charged the full appointment fee of $175 (individual) or $195 (couples/family).
I will negotiate exceptions for emergencies such as sudden illness or accident on an individual, per time basis. Repeated cancellations without explanation or missing more than 75% of scheduled session may result in discussion of termination of services.
If you are more than 15 minutes late for a scheduled session and do not contact therapist regarding arrival time, your session will be charged for the full fee outlined for the scheduled/missed service.
Future appointments after a client fails to provide notice of absence may be cancelled and require rescheduling with therapist to avoid future late fees.
Regarding couple and family therapy
In couple or family therapy I hold a “no-secrets” policy. This means that if information which may negatively impact couple counseling is disclosed by Person A in an individual session, I will not keep the secret from Person B in our joint sessions. However, I will first work with you in finding a way for you to personally disclose such information to your partner, spouse, parent, child, or other loved one with whom you are participating in therapy. Please note that this is different than the policy for a client in individual counseling and his or her privilege of confidentiality. In addition, if a request is made for the records of couple or family therapy to be disclosed to a third party, records will only be released with the consent of all adult parties, and any information that is released to a third party or to an individual within the couple or family will be released to both members of the couple or to all adults engaging in family therapy. This “no secrets” policy is intended to allow me to continue to provide therapy to the family or couple by preventing, as much as possible, conflicts of interest that may arise. If you feel it necessary to talk about matters that you do not wish to have disclosed, you should consult with a separate therapist for individual treatment.
If you are involved in divorce or parental responsibility/parenting time (custody) legal proceedings, my role as a therapist is not to make recommendations to the court concerning parental responsibility/ parenting time or parenting issues. By signing this Disclosure Statement, you agree not to subpoena me to court for testimony or for disclosure of treatment information in such legal proceedings; and you agree to not ask me to write any reports to the court or to your attorney, making recommendations concerning parental responsibility.
Confidentiality
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 confidentiality, some of which are listed in section 12-245-220 of the Colorado Revised Statutes, as well as other exceptions in Colorado and Federal law. For example, mental health professionals are required to report in the following circumstances: (a) child or elder abuse; (b) you are in imminent danger to self or others; (c) subpoena of records. If a legal exception arises during therapy, if feasible, you will be informed accordingly.
More explicit examples of legally mandated reports:
If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person, including persons identifiable by their association with a specific location or entity.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person or at-risk adult who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate court order for information stated on the order.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
Please be advised that there is no time limit on the mandatory reporting of child abuse. This means that even adult clients who experienced childhood abuse (no matter how long ago) might disclose in therapy past abuse incidents that still fall under the mandatory reporting requirements. The law requires that if there is reasonable cause to know or suspect that the perpetrator has subjected any other child currently under eighteen years of age to abuse or neglect or to circumstances or conditions that would likely result in abuse or neglect and/or is in any “position of trust” with children today then past abuse disclosed by an adult client is required to be reported. If you have questions or concerns about these requirements, please discuss further with me.
In situations such as those outlined above, I may be required to take protective actions which may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If such a situation arises during our work together, I will make every attempt to discuss it fully with you before taking necessary action.
In addition, I may disclose confidential information in the course of consultation with other professionals. I will make every effort to avoid revealing your identity in the course of such consultation, and any professional with whom I consult will be legally bound to keep the information confidential. Signing this document gives me permission to consult as necessary. I may also reveal confidential information in the event of an investigation of a complaint or civil suit filed against me or if I am ordered to do so by a court of law. In addition, there may be other exceptions to confidentiality as provided by HIPAA regulations and other Federal and/or Colorado laws and regulations that may apply.
Communications outside of scheduled sessions: Telephone Calls and Emergencies
I am available via phone, email or text and will return your call within 24 hours. I do not provide 24-hour emergency coverage.
If you have an emergency please call 911 or the crisis hotline at 1-844-493-8255.
Communications requiring more than appointment scheduling or passing information to me are best handled via scheduling an in- person or HIPAA compliant video session. I am happy to receive texts or phone calls; however, beyond 10-15 minutes we will need to schedule an appointment. Phone calls longer than 10 minutes are subject to billing. If I have time available, we can decide to extend our phone time with the understanding that I will need to charge on a pro- rated basis of my hourly fee either by HALF session fee (11-25 minutes) or FULL session fee (26-50 minutes). Written reports requested by insurance companies, physicians, etc. are subject to my hourly rate unless very brief.
There are both risks and benefits inherent in therapy. Please ask me about these in relation to your specific case. There may be psychological side effects from counseling. This risk comes with any therapy. You may share painful memories and experiences. Our goal is to welcome and confront these issues, and with time, we hope any negative side effects will lessen and our work together will benefit you. Additionally, there are no guarantees regarding the outcome of therapy.
Email and Text Communications
You may select to communicate with me via email at my HIPAA compliant email address listed above. You may agree or disagree to email in your simple practice portal.
Given that email might be generated from, or to, your office, there is no way to guarantee the confidentiality of the email at that end of the communication. Please only provide personal email address (not business or corporate emails) if you agree to email communications. SimplePractice portal communication is best to ensure HIPAA compliant exchange of information.
General information regarding your issue can be discussed via email. However, specifics related to your issues will need to be accomplished with a phone call /video session or face to face session.
Text communication through Guided Revolution LLC is transmitted through Google Voice. You can consent to text/voice communications in your personal Simple Practice portal. G-Suite, Google Workspace and Google Voice is considered HIPAA compliant with an established BAA. However, text communication is not appropriate for mental health crises, safety concerns, or to discuss explicit session content. Please send private information via email, the Simple Practice portal, or via face to face communication during scheduled sessions.
If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
Interruption of Services – Professional Designee
In the event that I am disabled, die, or become incapacitated, the following provider will act as my Professional Designee and will have access to my client files: Cara Czarnecki, LMFT. The Professional Designee will contact you to notify you of the event and will assist in continuing your care and treatment with the least amount of disruption possible by providing you with referrals and transferring your client record, if requested, to your new provider. If you are not comfortable with the above listed Professional Designee for any reason, please let me know and we will discuss alternatives.
Social Media Policy
I do not accept personal Facebook, LinkedIn, Twitter, Instagram, and/or other friend/connection/follow requests via any Social Media. Any such request will be denied in order to maintain professional boundaries. I have, or may have, a business social media account page, but there is absolutely no requirement that you “like” or “follow” this page. If you should “like” or choose to “follow” my business social media page, you understand that others will see your name associated with “liking” or “following” that page. You also understand that this applies to any comments that you post on my page/wall. Any comments you post regarding therapeutic work between us will be deleted as soon as possible. You agree that you will refrain from discussing, commenting, and/or asking therapeutic questions via any social media platform, including online review sites and you will instead discuss any concerns or questions with me directly.
If you have any questions regarding social media, review websites, or search engines in connection to my therapeutic relationship, please contact me immediately and address those questions.
Treatment of Minors
If you are consenting to the treatment of a minor child, you will be required to provide a copy of the most recent Court Order Custody Agreement and/or Parenting Plan, if applicable, that gives you the authority to consent to the treatment of the child. By signing this form, you agree to keep me informed of any supplemental court orders or other proceedings that impact your parental rights, custody arrangements, or decision-making authority. Failure to produce the Court Order will prohibit me from seeing the minor child. If there is joint medical decision-making authority for your child, I will require both parents to consent to treatment and will not proceed until such consent is obtained.
It is beyond the scope of my practice to provide custody recommendations, and any such request will be denied. The Court can appoint professionals who have the expertise to make such recommendations. By signing below, you agree not to subpoena my records or ask me to testify in court or to provide letters or documentation expressing my opinion about custody or visitation. Despite this, a Court may still require me to testify or to provide treatment information to an evaluator. I will comply with these requests as legally required and you will be required to compensate me for time spent providing these services as indicated in the fees section above.
In the course of treatment with your child, I may involve other family members in your child’s treatment. However, please remember that my client is your child, not the other family members of the child. Any meetings with you or other family members will be documented in your child’s record. These notes will be available to anyone who has legal access to your child’s treatment record.
When treating a minor client where there is a custody arrangement between the parents or legal guardians (such as a divorce or separation), it is my policy to communicate with both parents/guardians via email (i.e. all communication will “cc” both parties). This policy is necessary to maintain transparency and professionalism, and to ensure the well-being of the therapeutic relationship with the minor client.
Therapy is most effective when there is a trusting relationship between the therapist and client. Privacy is important in establishing trust, and as a result, it is often important for child or adolescent clients to have a level of privacy around the therapy. It is my policy to provide parents with general information about their child’s treatment, but not to share specific information disclosed during therapy. This includes behaviors that you may not approve of but which do not place your child at imminent risk or danger. If I ever feel that your child is in danger, I will communicate this information to you. By way of example, if your child tells me that s/he has tried alcohol a few times at parties, I will not generally share this with you. If your child shares that s/he has been drinking and driving or riding with a drunk driver, I would share this information with you. If you have questions about the types of information I will share, you can feel free to ask me hypothetical questions about situations that I would or would not disclose to you.
Although you may have the legal right to access any written record I keep, by signing this agreement you are agreeing that your child or adolescent should have privacy around their therapy and you agree not to request access to your child’s full record.
Termination
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.
Agreement and Acceptance:
Please do not hesitate to ask for clarification or further information if necessary. By signing below, you confirm that you have read, understood the preceding information, and that you agree to the stated terms, fees and policies and are giving Meghan Montgomery, MAAT, LPC & Guided Revolution Counseling & Art Therapy LLC. consent to treat. 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
BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.