Client Portal for Aliza Shapiro

Affordable Counseling Program Intern

(720) 828-3030

AlizaShapiro@PeopleHouse.org

Intake Forms

Aliza Shapiro Disclosure Statement

Disclosure Statement

Aliza Shapiro, MA Candidate, University of Colorado - Denver 720-828-3030 AlizaShapiro@peoplehouse.org

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. Any questions, concerns, or complaints regarding the practice of mental health may be directed to: Colorado Department of Regulatory Agencies (DORA) Mental Health Licensing Section 1560 Broadway, Suite 1350, Denver, CO 80202 Phone: (303) 894-7800 Website: www.colorado.gov/dora You are entitled to receive information about the methods and techniques of therapy I use, the duration of therapy (if known), my 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.

Confidentiality All information provided to me by you in our professional relationship is confidential except in the following circumstances: You sign a Release of Information for a specific individual or agency. There is reasonable suspicion of child abuse, elder abuse, or abuse of a vulnerable adult. You present an imminent danger to yourself or others. Records are subpoenaed in a criminal procedure. I am required to report any suspected threat to national security. Additionally, I will consult with a treatment team of supervisors and interns in the Affordable Counseling Program at People House, Naropa University and/or a medical backup. The purpose of consultation is to enhance my ability to help you, and these professionals are required to follow the same standards of confidentiality previously described.

Retention of Records Your records will be retained for seven (7) years from the date of your last session (or seven years after a minor client turns 18). After this period, records will be securely destroyed. You may request copies of your records in writing during the retention period.

Education/Training/Credentials I am a counseling student at the University of Colorado Denver, obtaining my master’s degree in Counseling. I have a Bachelors degree in Anthropology from Tufts University, where I also studied Communications. My years working as a personal fitness trainer and experience with Vipassana meditation have informed my work with somatic-based practice. Extensive training with the Enneagram, alongside several years of working with Dr. Pat B. Allen, PhD, ATR in the realm of expressive arts techniques for accessing spirituality have informed my spiritual and creativity-focused orientation . My supervisor at People House is Dee Marcotte, LPC, Certified Animal Assisted Psychotherapist, Certified Sex Addiction Therapist, and Approved Clinical Supervisor.

Video/audio recording item: Part of my graduation requirement involves reviewing a video or audio recording with my supervisor. If I ask your permission to record a session you always have the right to decline. If you choose to participate, I will give you advance notice and review a recording authorization with you.

Theoretical Perspective I work from a systems-based, feminist, integrative perspective that draws on multiple counseling theories to best meet your needs. I collaborate with you to understand the struggles you face and how you can make the changes you desire. My work may incorporate theory and techniques from narrative therapy, experiential modalities, existential, and acceptance and commitment therapy . When working with couples and families I draw from systems, transgenerational, and emotionally focused therapies. I believe it is essential to understand the context of people’s lives and the various systems that dictate the conditions you are navigating. I may ask about others who are important in your life, cultural influences, and how you are impacted by societal pressures and oppressions. Together we will work to make positive changes in your life, working in a holistic manner that addresses the mind, body, emotions, spirit, and social environment.

Services, Fees and Payment I offer individual, couples, and family therapy, as well as periodic workshops and therapy groups. Fees for my services as a part of the Affordable Counseling Program at People House are on a sliding scale of $25-$65. Payment is expected at the time of service via cash, check, or credit/debit card through a HIPAA-compliant payment processing system. I will send you a text with information on how to use the system. Your credit card information is entered into an encrypted system, People House does not have any access to your payment related information. For more information on the privacy policy of Ivy Pay please visit their webpage https://www.talktoivy.com/ivypay/privacy-policy. As outlined in this section, my fee is $25-$65/session. I typically see clients 2-4 times per month. The monthly cost of treatment can be determined by multiplying your scheduled sessions by my fee. Due to a variety of factors, it is not possible to provide an exact prediction of length of treatment, though many clients receive ACP services through my graduation date of April 30, 2026. As we work together, additional services may be recommended. This estimate of your costs is only an estimate, and your actual charges may differ. You have the right to initiate the patient–provider dispute resolution process if the charges you billed substantially exceed the expected charges in this estimate. This estimate of costs is not a contract and does not obligate you to obtain clinical services from me. People House does not accept or work with insurance, including Medicaid or Medicare. If you have Medicaid, paying out of pocket may impact your eligibility for covered services. It is your responsibility to consult your Medicaid provider regarding this.

Medicaid Acknowledgment 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. By initialing below, you are confirming that you are not currently a Medicaid recipient and that you agree to notify me if that status changes.

Cancellations Since I have reserved your appointment time exclusively for you, I require at least 24 hours’ notice for cancellations. Late cancellations or no-shows will be charged the full session fee agreed upon at the start of treatment. Exceptions may be made for emergencies, such as sudden illness or severe weather.

Couple/Family Counseling Sessions with couples/families will be charged at the same rate as individual counseling; however the sessions may be extended to 75-90 minutes and the fee will be pro-rated accordingly. Should I see any family member in a private session I reserve the right to bring that information into the joint session if I feel it is necessary to treatment of the couple/family. Please note this is different than individuals in counseling and their privilege of confidentiality. With couples counseling or family counseling, I have a no-secrets policy. The relationship or group itself is considered to be the client. Any information shared privately with me will not be withheld from the other members that comprise the couple or group. A request to share something confidential with me can be utilized in preparation for sharing this with all parties the following meeting.

Location Our sessions will be held either at the main People House location (3035 W. 25th Ave Denver, CO 80211), at People House East (13693 E. Iliff Ave. Suite 112, Aurora, CO 80014), or virtually. Please be aware that the office building in which PH East is located also houses a sex offender treatment program which has no connection to People House.

Informed Consent for Telehealth People House offers in-person and virtual therapy sessions. If you choose to participate in telehealth services, you will be required to review and sign a separate Informed Consent for Telehealth form. This form outlines the risks, benefits, and limitations of virtual sessions, as well as the requirement that clients must be physically located in Colorado during telehealth appointments.

Emergency Contact Information I am available to return business calls between 9 AM and 7 PM, Monday through Friday. If I am out of town, I will provide you with an alternative contact. I do not provide 24-hour emergency coverage. If you have an emergency, please contact: Colorado Crisis Services: 1-844-493-8255or Call 911 or visit your nearest emergency room.

Communication & Electronic Correspondence Please be aware that text messages, emails, and other electronic communication are not fully secure or HIPAA-compliant. If you choose to communicate electronically, you acknowledge the risks. Any email or text message relevant to your treatment may become part of your medical record.

Dual Relationship Policy I will not engage in social, financial, or professional relationships with current clients, including hiring clients for services or accepting significant gifts, as this could compromise professional boundaries. If any concerns arise, please discuss them with me directly.

Reasons for Early Termination of Services Our therapeutic relationship in the ACP will conclude when I graduate from the program April 30th, 2025. However, therapy may be terminated earlier if: ● It is determined that my services are not a fit for your needs, and an appropriate referral will be provided. ● You violate People House’s policies or exhibit behavior that is abusive, violent, or manipulative. ● You misrepresent your identity or attempt to manipulate the sliding scale fee structure. In addition you agree to work with only one ACP therapist for individual counseling at a time. This does not apply if you are seeing different ACP therapists for individual and family/couple counseling. In all cases of termination, I will provide referrals as appropriate.

Litigation Limitation Due to the nature of therapy, it is agreed that should there be legal proceedings (e.g., divorce, custody disputes, lawsuits), neither you (client) nor your attorney will call me to testify in court. If I am subpoenaed despite this limitation, you agree to pay all costs incurred at an hourly rate of $250/hour. In such cases, I reserve the right to terminate therapy, as legal involvement may compromise the therapeutic relationship.

Agreement and Acceptance

I,

have read and agree to the preceding information. I have also received and read the HIPAA Confidentiality Information Regarding Psychotherapy and Privacy Notification attachments. I understand my rights and responsibilities as a client and I have had an opportunity to ask questions.

I agree

Client Signature

Clear

Date

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A Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor 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. 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 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 bachelor’s 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 master’s degree and meet the CAC III requirements. A Registered Psychotherapist is registered with the State Board of Registered Psychotherapists, is not licensed or certified, and no degree, training or experience is required. 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 the Department of Regulatory Agencies (DORA) can be reached at 1560 Broadway, Ste. 1350, Denver, CO 80202, (303) 894-7800.

People House Affordable Counseling Program 3035 W. 25th Ave. Denver, CO 80211 ~ Phone 303-480-5130 ~ Fax 303-480-3646 ~ www.peoplehouse.org

PRIVACY NOTIFICATION The following information includes the new federal regulations that took effect as of April 14, 2003. Many of the items in this notification will not apply to you and the counseling environment. However, in order to be in compliance with the federal requirements, I am listing all of the information in this notification. I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. II. IT IS MY LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI). By law I am required to insure that your PHI is kept private. The PHI constitutes information created or noted by me that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. I am required to provide you with this Notice about my privacy procedures. This Notice must explain when, why, and how I would use and/or disclose your PHI. Use of PHI means when I share, apply, utilize, examine, or analyze information within my practice; PHI is disclosed when I release, transfer, give, or otherwise reveal it to a third party outside my practice. With some exceptions, I may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, I am always legally required to follow the privacy practices described in this Notice. Please note that I reserve the right to change the terms of this Notice and my privacy policies at any time. Any changes will apply to PHI already on file with me. Before I make any important changes to my policies, I will immediately change this Notice and post a new copy of it in my office and on my website. You may also request a copy of this Notice from me, or you can view a copy of it in my office. III. HOW I WILL USE AND DISCLOSE YOUR PHI. I will use and disclose your PHI for many different reasons. Some of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of my uses and disclosures, with some examples. I have underlined the most pertinent to the counseling environment. A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. I may use and disclose your PHI without your consent for the following reasons: 1. For treatment. I may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. Example: If a psychiatrist is treating you, I may disclose your PHI to her/him in order to coordinate your care. Personally, my procedure is to acquire a Release of Information prior to the disclosure and/or to be sure that the provider has already obtained a Release of Information from you. If I am not able to have a written Release from you prior to the discussion, I will ask you to sign one after the conversation. However, prior to the discussion I will obtain a Verbal Release from you. 2. For health care operations. I may disclose your PHI to facilitate the efficient and correct operation of my practice. Examples: Quality control - I might use your PHI in the evaluation of the quality of health care services that you have received or to evaluate the performance of the health care professionals who provided you with these services. I may also provide your PHI to my attorneys, accountants, consultants, and others to make sure that I am in compliance with applicable laws. 3. To obtain payment for treatment. I may use and disclose your PHI to bill and collect payment for the treatment and services I provided you. Example: I might send your PHI to your insurance company or health plan in order to get payment for the health care services that I have provided to you. I could also provide your PHI to business associates, such as billing companies, claims processing companies, and others that process health care claims for my office. In my practice, I do not use business associates such as billing companies, claims processing companies or similar services. As such, this only applies to bill and collect from your insurance company and I do not do that electronically at this time. 4. Other disclosures. Examples: Your consent isn't required if you need emergency treatment provided that I attempt to get your consent after treatment is rendered. In the event that I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) but I think that you would consent to such treatment if you could, I may disclose your PHI. In the case of counseling, this will usually only apply to any time I would need to break confidentiality. B. Certain Other Uses and Disclosures Do Not Require Your Consent. I may use and/or disclose your PHI without your consent or authorization for the following reasons: 1. When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: I may make a disclosure to the appropriate officials when a law requires me to report information to government agencies, law enforcement personnel and/or in an administrative proceeding. These times are listed in the Disclosure Statement. 2. If disclosure is compelled by a party to a proceeding before a court of an administrative agency pursuant to its lawful authority. 3. If disclosure is required by a search warrant lawfully issued to a governmental law enforcement agency. 4. To avoid harm. I may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person or the public. 5. If disclosure is compelled or permitted by the fact that you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if I determine that disclosure is necessary to prevent the threatened danger. 6. If disclosure is mandated by the Colorado Child Abuse and Neglect Reporting law. For example, if I have a reasonable suspicion of child abuse or neglect. 7. If disclosure is mandated by any Abuse Reporting law. For example, if I have a reasonable suspicion of elder abuse or dependent adult abuse. 8. If disclosure is compelled or permitted by the fact that you tell me of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims. 9. For public health activities. Example: In the event of your death, if a disclosure is permitted or compelled, I may need to give the county coroner information about you. 10. For health oversight activities. Example: I may be required to provide information to assist the government in the course of an investigation or inspection of a health care organization or provider. 11. For specific government functions. Examples: I may disclose PHI of military personnel and veterans under certain circumstances. Also, I may disclose PHI in the interests of national security, such as protecting the President of the United States or assisting with intelligence operations. 12. For research purposes. In certain circumstances, I may provide PHI in order to conduct medical research. 13. For Workers' Compensation purposes. I may provide PHI in order to comply with Workers' Compensation laws. 14. Appointment reminders and health related benefits or services. Examples: I may use PHI to provide appointment reminders. I may use PHI to give you information about alternative treatment options, or other health care services or benefits I offer. 15. If an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel. 16. I am permitted to contact you, without your prior authorization, to provide appointment reminders or information about alternative or other heath-related benefits and services that may be of interest to you. 17. If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law. Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess my compliance with HIPAA regulations. 18. If disclosure is otherwise specifically required by law. 19. Please note that I will generally obtain your consent. These are the new guidelines set up by HIPAA C. Certain Uses and Disclosures Require You to Have the Opportunity to Object. 1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other individual who you indicate is involved in your care or responsible for the payment for your health care, unless you object in whole or in part. Retroactive consent may be obtained in emergency situations. D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in Sections IIIA, IIIB, and IIIC above, I will request your written authorization before using or disclosing any of your PHI. Even if you have signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any future uses and disclosures (assuming that I haven't taken any action subsequent to the original authorization) of your PHI by me. IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI (In general this is your health record) These are your rights with respect to your PHI: A. The Right to See and Get Copies of Your PHI. In general, you have the right to see your PHI that is in my possession, or to get copies of it; however, you must request it in writing. If I do not have your PHI, but I know who does, I will advise you how you can get it. You will receive a response from me within 30 days of my receiving your written request. Under certain circumstances, I may feel I must deny your request, but if I do, I will give you, in writing, the reasons for the denial. I will also explain your right to have my denial reviewed. If you ask for copies of your PHI, I will charge you not more than $.25 per page. I may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance. B. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that I limit how I use and disclose your PHI. While I will consider your request, I am not legally bound to agree. If I do agree to your request, I will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that I am legally required or permitted to make. C. The Right to Choose How I Send Your PHI to You. It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail). I am obliged to agree to your request providing that I can give you the PHI, in the format you requested, without undue inconvenience. D. The Right to Get a List of the Disclosures I Have Made. You are entitled to a list of disclosures of your PHI that I have made. The list will not include uses or disclosures to which you have already consented, i.e., those for treatment, payment, or health care operations, sent directly to you, or to your family; neither will the list include disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, 2003. After April 15, 2003, disclosure records will be held for six years. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I give you will include disclosures made in the previous six years (the first six year period being 2003-2009) unless you indicate a shorter period. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no cost, unless you make more than one request in the same year, in which case I will charge you a reasonable sum based on a set fee for each additional request. E. The Right to Amend Your PHI. If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that I correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of my receipt of your request. I may deny your request, in writing, if I find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of my records, or (d) written by someone other than me. My denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and my denial be attached to any future disclosures of your PHI. If I approve your request, I will make the change(s) to your PHI. Additionally, I will tell you that the changes have been made, and I will advise all others who need to know about the change(s) to your PHI. F. The Right to Get This Notice by Email. You have the right to request a paper copy of it, as well. V. HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES If, in your opinion, I may have violated your privacy rights, or if you object to a decision I made about access to your PHI, you are entitled to file a complaint with the person listed in Section VI below. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W. Washington, D.C. 20201. If you file a complaint about my privacy practices, I will take no retaliatory action against you. VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT MY PRIVACY PRACTICES If you have any questions about this notice or any complaints about my privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact me at: 303-829-6422 VII. EFFECTIVE DATE OF THIS NOIICE this notice went into effect on April 14, 2003.

I have read the HIPAA Privacy Notification

I agree

People House Affordable Counseling Program 3035 W. 25th Ave. Denver, CO 80211 ~ Phone 303-480-5130 ~ Fax 303-480-3646 ~ www.peoplehouse.org

Confidentiality Information Regarding Psychotherapy This form provides you (patient) with information that is additional to that detailed in the Notice of Privacy Practices. The following information includes the federal regulations that took effect as of April 14, 2003. Many of the items in this notification will not apply to you and the counseling environment. However, in order to be in compliance with the federal requirements, we are listing all of the information in this notification. CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client's) written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the Disclosure Statement that you received with this form. When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; and where a client presents a danger to self, to others, to property, or is gravely disabled. When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by this therapist. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. We will not reveal information regarding couple/child therapy unless BOTH parties are willing to sign a Release of Information. We will not release records to any outside party unless we are authorized to do so by all adult family members who were part of the treatment. We will release information regarding any individual who can give a release for information regarding their experiences in therapy. Emergencies: If there is an emergency during our work together, or in the future after termination, where your counselor becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, we will do whatever we can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, we may also contact the person whose name you have provided on the biographical sheet. Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct your counselor, only the minimum necessary information will be communicated to the carrier, unless authorize by you explicitly the Psychotherapy Notes will not be disclosed to your insurance carrier. We have no control or knowledge over what insurance companies do with the information he/she submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance. The risk stems from the fact that mental health information is entered into insurance companies' computers and soon will also be reported to the, congress-approved, National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question, as computers are inherently vulnerable to break-ins and unauthorized access. Medical data has been reported sold, stolen, or accessed by enforcement agencies in the past; therefore, you are in a vulnerable position. Confidentiality of E-mail, Cell Phone and Fax Communication: It is very important to be aware that e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence, the privacy and confidentiality of such communication can be compromised. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Faxes can easily be sent erroneously to the wrong address. Please notify your counselor at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices. Please do not use e-mail or fax for emergencies. Please note that the business number for your counselor may be a cell phone. Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call us to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested. Consultation: Your counselor consults regularly with other professionals regarding his/her clients; however, the client's name or other identifying information is never mentioned. The client's identity remains completely anonymous, and confidentiality is fully maintained. Considering all of the above exclusions, if it is still appropriate, upon your request, we will release information to any agency/person you specify unless she concludes that releasing such information might be harmful in any way. TELEPHONE & EMERGENCY PROCEDURES: Please refer to the Fees & Policies Statement for this information. Please call 911 if you are in danger. PAYMENTS & INSURANCE REIMBURSEMENT: Please refer to your copy of the Fees/Policies Statement regarding fees, times of sessions, etc. Telephone conversations, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer session, travel time, etc. will be charged at the same rate as regular sessions, unless indicated and agreed otherwise. Please notify me if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, I will provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement if you so choose. As was indicated in the Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of psychotherapy are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. MEDIATION & ARBITRATION: All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of your counselor and client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Denver County, in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, we can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys' fees. In the case of arbitration, the arbitrator will determine that sum. THE PROCESS OF THERAPY/EVALUATION: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits; however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. We will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc. or experiencing anxiety, depression, insomnia, etc. your counselor may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed as a negative one by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, your counselor is likely to draw on various psychological approaches according, in part; to the problem that is being treated and his/her assessment of what will best benefit you. Discussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment, I will discuss with you (client) his/her working understanding of the problem, treatment plan, therapeutic objectives, and his/her view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, my expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that I do not provide, I have an ethical obligation to assist you in obtaining those treatments. Termination: During the first meeting, we will assess if I can be of benefit to you. I do not accept clients who, in my opinion, I cannot be of benefit to. In such a case, I will give you a number of referrals that you can contact. If at any point during psychotherapy, this is not effective in helping you reach your therapeutic goals, I am obliged to discuss it with you and, if appropriate, to terminate treatment. In such a case, I would give you a number of referrals that may be of help to you. If you request it and authorize it in wring, I will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and, if I have your written consent, will provide him/her with the essential information needed. See Fees & Policies Statement of further information. CANCELLATION: Please see the Fees and Policies Statement. DUAL RELATIONSHIPS: Not all dual relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs objectivity, clinical judgment, or therapeutic effectiveness or can be exploitative in nature. If it was necessary, I will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients. In general, I will avoid creating any type of dual relationship with a client. I will never acknowledge working therapeutically with anyone without your written permission. Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it and often it is impossible to know that ahead of time. If for some reason, a dual relationship inadvertently occurs, it is your, the client’s, responsibility to communicate to me if the dual relationship becomes uncomfortable of you in any way. I will always listen carefully and respond accordingly to your feedback and will discontinue the dual relationship if I find it interfering with the effectiveness of the therapeutic process or the welfare of you the client and, of course, you can do the same at any time. As a client in the People House Affordable Counseling Program, I acknowledge that I have read the above Agreement, which was given to me at intake, and by signing the Disclosure Statement of the People House intern counselor; I affirm that I understand and agree to comply with this Agreement.

I have read the HIPAA Confidentiality Information Regarding Psychotherapy

I agree

If you are human, leave this field blank.

Δ

Client Intake Questionnaire

Aliza Shapiro Therapeutic Client Intake Questionnaire

Name *

Name

First

Last

Age *

Date of Birth

I identify my gender as

My pronouns are

Ethnicity

Asian or Pacific Islander

Black or African American

Hispanic or Latino/a/e/x

Native American or Alaskan Native

White or Caucasian

Multiracial or Biracial

A race or ethnicity not listed here

Why are you seeking counseling? *

Addiction

Anger

Anxiety

Career

Crisis

Divorce

Depression

General growth

Grief/Loss

Illness/Health issues

Life transitions

Panic

Parenting

PTSD

Relationship issues

Trauma

Self-esteem

Spiritual growth

Stress

Work issues

OtherOther

Please list any other reasons you are seeking counseling here, and/or include any preferences, hopes, fears, reservations, or special needs you may have regarding counseling:

What is your ability to pay, per session? *

$25

$30

$35

$40

$45

$50

$55

$60

$65

Are you employed? *

Full time

Part time

Unemployed

Type of counseling: *

Individual

Couple

Family

Preference of People House location: *

Denver

Aurora

Virtual

Contact Information

Street Address *

City *

Zip Code *

County *

Email *

Is it okay to email you? *

Yes

Cell Phone Number *

Is it okay to leave a voicemail? *

Yes

Is it okay to text? *

Yes

Home phone number

Is it okay to leave a voicemail?

Yes

Work phone number

Is it okay to leave a voicemail?

Yes

Emergency Contact Information

Emergency Contact Name *

Emergency Contact's Phone Number *

Alternate Emergency Contact Name

Alternate Emergency Contact Phone Number

Career/Education Information

What is your income? *

No income

Below $15K

$15K - $20K

$20K - $30K

$30K - $40K

$40K - $50K

$50K - $60K

$60K+

Occupation

Place of work

Education level *

6th

7th

8th

9th

10th

11th

12th

Some college

Associates

Bachelors

Masters

PhD

Family Information

Relationship Status *

Single

In relationship/s

Married

Seperated

Divorced

If in relationship please list partner/spouse name(s)

Do you have children?

Yes

If yes, please list their names

Do they live with you

Full time

Part time

N/A

Health Information

Are you on any medication? *

Yes

If yes, please list medications/dosage

Frequency taken

What is the general condition of your health?

Physician name

Physician phone number

Please describe your physical and mental health including significant hospitalizations, illnesses

Are you currently receiving other mental health services or medical treatment? *

Yes

Safety Assessment

Have you ever given serious consideration to, or attempted to, end your own life? *

Yes

If yes, date of last occurrence - please describe:

If yes, do you currently feel this way? Do you have a plan?

Have you ever given serious consideration to, or attempted to harm another person: *

Yes

If yes, last occurrence:

If yes, do you currently feel this way? Do you have a plan?

History

Is there a history in your family of any of the following?

Alcoholism/Drugs

Eating Disorders

Emotional Abuse

Physical Abuse

Physical Disability Conditions

Rape

Sexual Abuse

Sleep Disorders

Violence

OtherOther

check all that apply

Which of the following areas have been or are a problem for you?

Alcohol/Drugs

Anger

Ability to control temper

Anxiety/Fear

Caffeine

Death/Major loss

Depression

Distance from loved ones

Disordered eating

Eating habits

Experienced discrimination

Family

Financial concerns

Friendships

Gender identity conflict

Health problems

Job/School

Legal

Loneliness

Marriage/Partner

Mood

Sleeping

Spirituality

Sexual difficulties

Smoking

Repetitive behavior

OtherOther

Check all that apply

Do you currently use tobacco, alcohol, or other drugs? *

Yes

Please list substances used currently or in the past? How much and how often?

Past substance use treatment?

Yes

Are you involved in the legal system or have you had significant legal issues in the past? *

Yes

If yes, please describe:

Please give me a brief family history. Describe family of origin and your current family dynamics:

Expectations for Therapy

What brings you to seek therapy now and what do you hope to gain?

Is there anything I have not asked you that is important for me to know?

What are your concerns about therapy?

Have you been in counseling before?

Yes

If yes, was your past experience positive or negative? Please explain:

How did you hear about the People House Affordable Counseling Program?

Return client

Transfer from another People House intern counselor

Friend or family member

Medical professional

Mental health professional

Crisis line

Employer/Coworker

People House website

Online search (search term used)Online search (search term used)

OtherOther

If you are human, leave this field blank.

Informed Consent for Teletherapy

Aliza Shapiro Teletherapy Consent Form

Informed Consent for Teletherapy

Aliza Shapiro, MA Candidate, University of Colorado - Denver

People House
3035 West 25th Avenue 
Denver, Colorado, 80211
720-828-3030
AlizaShapiro@peoplehouse.org

This Informed Consent for Teletherapy contains important information concerning engaging in electronic psychotherapy or teletherapy. Please read this carefully and let me know if you have any questions. This consent applies only to clients physically within the State of Colorado seeking therapeutic treatment within the State of Colorado. This Informed Consent for Teletherapy shall be signed in conjunction with my Disclosure Statement.

Benefits and Risks of Teletherapy

Teletherapy refers to the remote provision of psychotherapy services using telecommunications technologies such as video conferencing or telephone. One of the benefits of teletherapy is that the client and therapist can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or therapist moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It can also increase the convenience and time efficiency of both parties. 

Although there are benefits of teletherapy, there are some fundamental differences between in-person psychotherapy and teletherapy, as well as some inherent risks. For example: 
	• Risks to confidentiality. Because teletherapy sessions take place outside of the typical office setting, there is potential for third parties to overhear sessions if they are not conducted in a secure environment. Your counselor will take reasonable steps to ensure the privacy and security of your information, and it is important for you to review your own security measures and ensure that they are adequate to protect information on your end. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation. 
	• Issues related to technology. There are risks inherent in the use of technology for therapy that are important to understand, such as: potential for technology to fail during a session, potential that transmission of confidential information could be interrupted by unauthorized parties, or potential for electronically stored information to be accessed by unauthorized parties. 
	• Crisis management and intervention. As a general rule, your counselor will not engage in teletherapy with patients who are in a crisis situation. Before or during engaging in teletherapy, your counselor will develop an emergency response plan to address potential crisis situations that may arise during the course of our teletherapy work. 
	• Efficacy. While most research has failed to demonstrate that teletherapy is less effective than in person psychotherapy, some experienced mental health professionals believe that something is lost by not in the same room. For example, there is a debate about one’s ability when doing remote work to fully process non-verbal information.

Electronic Communications

We will discuss which is the most appropriate platform to use for teletherapy services. I will make my best efforts to comply with the Colorado Department of Regulatory Agency’s Teletherapy Policy, and I will provide you with a copy of these guidelines upon request. 

You may be required to have certain system requirements to access electronic psychotherapy via the method we choose. You are solely responsible for any cost to you to obtain any additional/necessary system requirements, accessories, or software to use electronic psychotherapy. 

For communication between sessions, I will use email communication and text messaging only with your permission and only for administrative purposes unless another agreement has been made. That means that email exchanges and text messages with me should be limited to things like setting and changing appointments, billing matters, and other related issues. You should be aware that the confidentiality of any information communicated by email or text cannot be guaranteed. Therefore, I will not include any clinical material by email and prefer that you do not as well. 

Treatment is most effective when clinical discussions occur at your regularly scheduled sessions, however if an urgent issue arises, you should feel free to attempt to reach your counselor by phone. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you cannot wait for a return call, contact your family physician or the nearest emergency room.

Confidentiality

I have a legal and ethical responsibility to make my best efforts to protect all communications, electric and otherwise, that are a part of teletherapy. However, the nature of electronic communications technologies is such that we cannot guarantee that communications will be kept confidential and/or that a third party may not gain access to our communications. Even though we may utilize state of the art encryption methods, firewalls, and back-up systems to help secure our communication, there is a risk that our electronic communications may be compromised, unsecured, and/or accessed by a third party. 

The extent of confidentiality and the exceptions to confidentiality that are outlined in the Mandatory Disclosures and Informed Consent still apply in teletherapy. Please let me know if you have any questions about exceptions to confidentiality.

Appropriateness of Teletherapy

If at any time while engaging in teletherapy I determine that teletherapy is no longer the most appropriate form of treatment for you, I will discuss options of engaging in face-to-face in-person counseling or referrals to another professional in your location who can provide appropriate services.

Emergencies and Technology

Assessing and evaluating threats and other emergencies can be more difficult when conducting teletherapy than in traditional in-person therapy. Teletherapy does not provide emergency services.  As always, if you are experiencing an emergency situation, you can call 911 or go to your nearest emergency room. If you are having suicidal thoughts or making plans to harm yourself, you can call the Colorado Crisis Hotline at 844-493-TALK (8255) or the National Suicide Prevention Lifeline at 1-800-TALK (8255) for free 24-hour hotline support. 
If the session cuts out, meaning the technological connection fails, and you are having an emergency do not call your counselor back, but call 911, Call your counselor after you have called or obtained emergency services. 

If the session cuts out and you are not having an emergency, disconnect from the session and your counselor will wait two (2) minutes and then re-contact you via the teletherapy platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes then call your counselor on the phone number they provided you. 

If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time. 

Fees: The same fee rates shall apply for teletherapy as apply for in-person psychotherapy.

Informed Consent:

This agreement is intended as a supplement to the general informed consent that we agreed to at the outset of our clinical work together. Your signature below indicates agreement with its terms and conditions. This agreement is supplemental to my general informed consent and does not amend any of the terms of that agreement.

I, *

,the client, having been fully informed of the risks and benefits of teletherapy; the security measures in place, which include procedures for emergency situations; the fees associated with teletherapy; the technological requirements needed to engage in teletherapy; and all other information provided in this informed consent, agree to and understand the procedures and policies set forth in this consent.

Signature of Client *

Clear

Date *

If you are human, leave this field blank.

Initial Intake Rating Survey

Aliza Shapiro Initial Intake Survey

Initial Intake Survey

Aliza Shapiro
(720) 828-3030
alizashapiro@peoplehouse.org

Client Name

First

Last

My level of employment is

None

Poor

Fair

Average

Good

Excellent

N/A

My level of family stability is

None

Poor

Fair

Average

Good

Excellent

N/A

My level of relationship satisfaction is

None

Poor

Fair

Average

Good

Excellent

N/A

My ability to deal with stress and frustration is

None

Poor

Fair

Average

Good

Excellent

N/A

My ability to make healthy choices for myself is

None

Poor

Fair

Average

Good

Excellent

N/A

My ability to cope with adversity and problem solve is

None

Poor

Fair

Average

Good

Excellent

N/A

My resilience (ability to bounce back from hard times) is

None

Poor

Fair

Average

Good

Excellent

N/A

My ability/desire to contribute to the lives of others is

None

Poor

Fair

Average

Good

Excellent

N/A

My level of physical well-being is

None

Poor

Fair

Average

Good

Excellent

N/A

My level of spiritual well-being is

None

Poor

Fair

Average

Good

Excellent

N/A

If you are human, leave this field blank.

Surveys

Progress Survey

Aliza Shapiro Progress Survey

Progress Survey

Aliza Shapiro
(720) 828-3030
alizashapiro@peoplehouse.org

Client Name

First

Last

My level of employment is

None

Poor

Fair

Average

Good

Excellent

N/A

My level of family stability is

None

Poor

Fair

Average

Good

Excellent

N/A

My level of relationship satisfaction is

None

Poor

Fair

Average

Good

Excellent

N/A

My ability to deal with stress and frustration is

None

Poor

Fair

Average

Good

Excellent

N/A

My ability to make healthy choices for myself is

None

Poor

Fair

Average

Good

Excellent

N/A

My ability to cope with adversity and problem solve is

None

Poor

Fair

Average

Good

Excellent

N/A

My resilience (ability to bounce back from hard times) is

None

Poor

Fair

Average

Good

Excellent

N/A

My ability/desire to contribute to the lives of others is

None

Poor

Fair

Average

Good

Excellent

N/A

My level of physical well-being is

None

Poor

Fair

Average

Good

Excellent

N/A

My level of spiritual well-being is

None

Poor

Fair

Average

Good

Excellent

N/A

If you are human, leave this field blank.

Exit Survey

Aliza Shapiro Exit Survey

Exit Survey

Aliza Shapiro
(720) 828-3030
alizashapiro@peoplehouse.org

Client Name

First

Last

My level of employment is *

None

Poor

Fair

Average

Good

Excellent

N/A

My level of family stability is *

None

Poor

Fair

Average

Good

Excellent

N/A

My level of relationship satisfaction is *

None

Poor

Fair

Average

Good

Excellent

N/A

My ability to deal with stress and frustration is *

None

Poor

Fair

Average

Good

Excellent

N/A

My ability to make healthy choices for myself is *

None

Poor

Fair

Average

Good

Excellent

N/A

My ability to cope with adversity and problem solve is *

None

Poor

Fair

Average

Good

Excellent

N/A

My resilience (ability to bounce back from hard times) is *

None

Poor

Fair

Average

Good

Excellent

N/A

My ability/desire to contribute to the lives of others is *

None

Poor

Fair

Average

Good

Excellent

N/A

My level of physical well-being is *

None

Poor

Fair

Average

Good

Excellent

N/A

My level of spiritual well-being is *

None

Poor

Fair

Average

Good

Excellent

N/A

Additional Information

What kept you coming back to People House?

Can you think of any obstacles that stop people from accessing community and mental health services at People House?

From time to time, we like to collect quotes from ACP clients about their experience in counseling at PH.

These quotes will be completely anonymous and could potentially be used for exemplars in our Annual Reports, End of the Year Thank you letters, etc. Writing a statement is not required but we would appreciate it:

If you are human, leave this field blank.

Other Forms

Group Disclosure Form

Camryn and Aliza Group Disclosure Statement Template

Disclosure Statement – Consent for Group Therapy

Camryn Clements, MA Candidate, University of Northern Colorado 
Aliza Shapiro, MA Candidate, University of Colorado - Denver 

 People House
3035 West 25th Avenue
Denver, Colorado, 80211
Main Line: 303-480-5130

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. Any questions, concerns, or complaints regarding the practice of mental health may be directed to: Mental Health Grievance Board, 1560 Broadway, Suite 1340, Denver, Colorado 80202, (303) 894-7766. You are entitled to receive information about the methods and techniques of therapy used, the duration of therapy (if known), as well as degrees, credentials, and licenses held by cotherapists. 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.

Purpose of the Group

Group therapy provides a supportive, confidential space in which participants can explore personal growth, interpersonal relationships, and emotional wellbeing. The purpose of this group is to foster insight, build connection, and strengthen coping and communication skills through shared experiences and reflection.

Confidentiality

All information provided to cotherapists Camryn Clements and Aliza Shapiro in our professional relationship is confidential except in the following circumstances: (a) you sign a release of information for a specific individual or agency; (b) child, elder, or dependent adult abuse; (c) you are in imminent danger to self or others; (d) subpoena of records in a criminal procedure; (e) we are required to report any suspected threat to national security. Additionally, we may consult with supervisors and interns in the Affordable Counseling Program at People House, the University of Colorado Denver, the University of Northern Colorado and/or medical backup professionals. All consultation is conducted under the same confidentiality standards. 
Group therapy works best when individuals feel safe to share and engage openly. Participants are expected to maintain confidentiality regarding other members, including names, personal identifiers, and shared information. While facilitators will emphasize this norm, confidentiality among members cannot be guaranteed.

Group Schedule/Attendance

Groups are held every Tuesday at 12 pm beginning on 2/10/2026 and ending on 4/7/2026, for a duration of 60 minutes. This is an open group, meaning group members can choose to attend all or one of the group sessions. Participants are encouraged to attend regularly to support group cohesion. Your contribution to the group process is valuable, and regular attendance helps foster trust and consistency.

Location

Group sessions will be held virtually. Virtual sessions will be conducted through a secure, HIPAA-compliant platform(Zoom).

Virtual Participation Guidelines

To maintain privacy and respect for the group process, please ensure you: - Participate from a private, quiet space. 
- Use headphones if possible. 
- Avoid multitasking or attending while in transit. 
- Do not record sessions or take screenshots. 
- Maintain confidentiality about what others share.

Group Norms

The following norms help ensure a safe and productive therapeutic environment: - Respect all group members and differing perspectives 
- Maintain confidentiality outside of sessions. 
- Allow space for everyone to share (avoid dominating the discussion). - Arrive on time and stay for the full session. 
- Communicate concerns directly and respectfully

Emergencies and Early Termination

If you experience a medical or mental health emergency, call 911, the Colorado Crisis Line at 1-844-493-8255, or go to your nearest emergency room. If technical or logistical issues arise during virtual sessions, your therapist will make reasonable attempts to reconnect. 
Group services may conclude due to completion of the term, client request, or clinical determination that the group format is no longer appropriate. Should group therapy end early, facilitators will provide appropriate referrals and transition support.

Litigation Limitation

Due to the confidential and personal nature of group therapy, neither you nor your attorney will request testimony or records from group leaders in any legal proceeding. 
By signing below, you affirm understanding and acceptance of the terms outlined in this disclosure.

Risks and Benefits Inherent in Group Therapy

There may be psychological side effects from counseling. This risk comes with any therapy. You may share painful things. Our goal is to 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. In a group setting, individuals may be offered support, feedback, participate in the practice of new interpersonal interactions, and partake in the sharing of experiences that can provoke intense emotional responses in others. All aforementioned responses and engagement are often fruitful, and should be processed in the group setting. If you determine that you are not best served in this setting or desire additional support, please contact your group leaders to discuss concerns and/or provide appropriate referrals.

Contact and Emergency Information

Each group member will provide the following information. This information is kept confidential and used only in case of a clinical or medical emergency during participation in group sessions.

Client Information

Full legal name *

Date of Birth *

Preferred name (If different)

Phone *

Email *

Address *

Address

City

State/Province

Zip/Postal

Country

Emergency Contact name *

Relationship to client (e.g., spouse, parent etc) *

Emergency Contact Phone *

Agreement and Acceptance

As a client working with intern counselors in the People House Affordable Counseling Program, I acknowledge that I have read the above Agreement, which was given to me at intake, and by signing the Disclosure Statement; I affirm that I understand and agree to comply with this Agreement. *

I agree

Client Signature *

Clear

Date *

Therapist Signature

Clear

Date

Therapist Signature

Clear

Date

If you are human, leave this field blank.

Informed Consent for Audio/Video Recording

Aliza Shapiro A/V Consent Form

Informed Consent for Audio/Video Recording

Aliza Shapiro, MA Candidate, University of Colorado - Denver

720-828-3030
AlizaShapiro@peoplehouse.org

As a graduate student, I am required to be under the direct supervision of a qualified clinical supervisor. My supervisor reviews all aspects of the services I am providing to you. Your signature below confirms you have read and understand the following:

●	I am not required and I am under no obligation to have this session recorded.
●	I may withdraw my permission at any time during or after the recording session.  My care will not change by my decision to not be recorded.
●	The contents of this recording will only be accessible by my therapist, and her supervisors, and team of therapists. 
●	This recording will only be used as a tool to aid in more accurate supervision.
●	The confidentiality of this recording will be maintained under the same guidelines as the content of a non-recorded session as stated in the HIPAA agreement.
●	The original copy of this consent form, as well as any written requests for revocation of consent, will be kept in my records.
●	This consent expires at the end of this calendar year 2025.  Although, I may revoke this consent at any time prior to the scheduled expiration by submitting a request in writing to my therapist, Aliza Shapiro.

I, *

(Client), give my consent to allow my therapist, Aliza Shapiro

to utilize *

audio recording and/or

video recording for use in supervision

Signature *

Clear

Name *

Name

First

Last

Date *

If you are human, leave this field blank.

Release of Information

Aliza Shapiro ROI

Authorization to Release Information

Aliza Shapiro, Intern Counselor

3035 W 25th Ave
Denver, CO 80211				 
720-828-3030

I, *

(hereinafter "Client") hereby authorize People House, (hereinafter "Provider") to disclose & receive mental health treatment information and records obtained in the course of psychotherapy treatment of Client, including, but not limited to, therapist's diagnosis of Client to/from: *

I understand that I have a right to receive a copy of this authorization. I understand that any cancellation or modification of this authorization must be in writing. I understand that I have the right to revoke this authorization at any time unless Provider has taken action in reliance upon it. And, I also understand that such revocation must be in writing and received by Provider at 3035 W. 25th Avenue, Denver, Co 80211 to be effective. This disclosure of information and records authorized by Client is required for the following purpose: *

The specific uses and limitations of the types of medical information to be discussed are as follows (be as specific as you choose to):

Presence in Treatment

Discharge Summary

Treatment Plan/Recommendation

Copy of Aftercare Plan (if applies)

Criminal Justice History

Probation/Parole Conditions

Verbal and Written Progress

Educational Information

Psychosocial History

Psychiatric History

Psychological Evaluation

Medication History

Physician's Orders

OtherOther

I understand that information to be released may include information listed above and/or information regarding the following:

Chemical Abuse and/or Dependency

Criminal Records

HIV/AIDS Testing or Status

Psychiatric Conditions

Judiciary Recommendations

OtherOther

Signature

Clear

Therapist shall not condition treatment upon Client signing this authorization and Client has the right to refuse to sign this form. I certify that this request has been made voluntarily. I understand that I may revoke this authorization at any time, except to the extent that action has been taken to comply with it.  I hereby release any service provider or individual from any liability, which may result from furnishing the information requested as authorized in this release.  

The Client understands that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule.

This authorization shall remain valid until:

Client Signature *

Clear

Date *

Therapist Signature

Clear

Date

If you are human, leave this field blank.

Downloadable Teletherapy Consent Form

Click HERE to download the Teletherapy Consent Form

Downloadable Disclosure Statement

Click HERE to download the Disclosure Statement

Downloadable Release of Information

Click here to download the ROI.