John Emmons, M. Div

Licensed Professional Counselor; Nationally Certified Counselor

1025 S Perry St., Suite C, Castle Rock, Colorado, 80104 303-660-2319

 

Disclosure Statement.

As a psychotherapist I am required to give you the following information:

The practice of both licensed and unlicensed persons and certified school psychologists in the field of psychotherapy is regulated by the Colorado State Department of Regulatory Agencies with a Mental Health Occupations Grievance Board that can be contacted at 1560 Broadway, Suite 1340, Denver, Colorado, 80202. (303) 894-7766.

You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy (if I can determine it), and my fee structure. Payment is due at the time of treatment unless it is paid by insurance. In this case, co-payment is due at the time of treatment. My fee is $75.00 per session unless other arrangements are made. I have the right to bill for any missed appointment unless twenty-four hour notification is given.

I am a Licensed Professional Counselor and a Nationally Certified Counselor. I possess a Master of Divinity from Denver Seminary and a Bachelor of Arts from Moody Bible Institute.

You can seek a second opinion from another therapist or terminate therapy at any time.

In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the State Grievance Board.

Generally speaking, information provided by and to a client during therapy sessions with a psychotherapist is legally confidential, and the therapist cannot disclose the information without the client's consent. All private communication in therapy will remain private except in the case of a serious potential for suicide or possible physical violence to another person. I am also obligated by law to report any known or suspected instance of child abuse. There are some other exceptions to this rule.

I have been informed of my therapist's degrees, credentials, and licenses, and consent to allow my therapist to share the content of our sessions with his consultant. I have also read the preceding information and understand my rights as a client.

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