Client Portal for Morgan Kautz

Affordable Counseling Program Intern

720-443-3117‬

MorganKautz@PeopleHouse.org

Intake Forms

Disclosure Statement

Morgan Kautz Disclosure Statement

Disclosure Statement

Morgan Kautz, MA Candidate, Regis University

720-443-3117
morgankautz@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: 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 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.

Confidentiality

All information provided to me by you 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 or elder abuse; (c) you are in imminent danger to self or others; (d) subpoena of records in a criminal procedure; (e) 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, Regis 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.

Education/Training/Credentials

I am a counseling student at Regis University, obtaining my Master’s degree in Counseling Psychology. I have a Bachelor’s in Psychology and Philosophy from Northern Illinois University, DeKalb, Illinois. At People House, I am under the supervision of Kristen Griego.

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 Humanist  perspective that integrates 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 Existential therapy, Gestalt therapy (experiential), Acceptance and Commitment Therapy (ACT), and Psychodynamic therapy. When working with couples, I draw from Emotionally Focused Therapy and the Gottman Method.

Services, Fees and Payment

I offer individual and couples  as well as periodic 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, which will be determined at the first session.  Payment is expected at the time of service and may be made with cash, check made payable to People House, or credit/debit card. We use a HIPAA compliant credit/debit card payment processing system. I will send you a text with the 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 information. For more information on the privacy policy of Ivy Pay please visit their webpage https://www.talktoivy.com/ivypay/privacy-policy.

People House does not accept or work with insurance of any kind including Medicaid or Medicare. (NOTE: Please be aware that if you have Medicaid insurance, your eligibility could potentially be compromised by paying out of pocket to receive covered services. It is your responsibility to discuss this issue with your Medicaid provider.) My policy for written reports requested by insurance companies, physicians, etc. will also be charged at my hourly rate unless very brief. Scheduling availability is not guaranteed if you do not have a repeating time slot.

Couple/Family Counseling

Sessions with couples 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 member of a couple 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.  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.

Cancellations

Since I have reserved your appointment time exclusively for you, it is my policy to receive at least a 24-hour cancellation notice or you will be charged for the appointment. I will negotiate exceptions for emergencies such as severe weather or sudden illness on an individual, per time basis.

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.

Telephone Calls and Emergencies

I am available to return business calls between 9am and 7pm, Monday through Friday. If I am out of town, I will give you the name and phone number of the associate covering for me while I am gone. I do not provide 24 hour emergency coverage. If you have an emergency please call your local 24 hour crisis line, 1-844-493-8255 or call 911. There is no charge for brief phone calls.  Calls lasting longer than l0 minutes will be charged on a pro-rated basis of my hourly fee.

Communication

Understand that communication over text is not guaranteed to be confidential and does not fall under the confidentiality requirements of HIPAA. If you choose to communicate over text, you understand the risks that come with texting confidential information.

Please note- any pertinent correspondence, including (but not limited to) electronic communications via email, text messages and shared documents are a part of your medical record.

Reasons for Early Termination of Services

Our therapeutic relationship in the ACP will conclude when I graduate from the program 8/31/25. In general our therapy will progress regularly until then unless you decide you would like to take a break from or end therapy. That said, in certain instances, I or my supervisor may determine that it is necessary to terminate therapy. Reasons for this include:
●	A determination is reached that our services, or my approach, is not a fit for your needs, and that you would be better served with a referral.
●	Behavior occurs that is abusive, violent, or malicious. 
●	An attempt is made to manipulate our system by lying, mis-identifying or mis-representing your identity or status. 
●	It is determined that you have sufficient means to pay more than the top of our sliding scale.
●	In such instances, I will inform you of the decision to terminate, and referrals will be provided to you. Should you want to discuss this further, I will provide you with the contact information for my supervisor, or for the Program Director.  
●	 Recording therapy sessions is not allowed without permission from my mental health care provider.
 Please note- Each client may have only one individual intern counselor at a time. Should you decide you would like to see a different intern for individual therapy please let me know so that we can close our work before you begin working with another intern. This same policy applies for each service provided (e.g. individual counseling, couples counseling, family counseling etc).  While you may see different interns for different services, seeing multiple interns for the same service is considered a violation of our policy and will result in a termination of services.

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 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.

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 me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.
In the situation where we (intern counselor and/or People House) are subpoenaed for any information in spite of this limitation, by reading and signing this disclosure, you agree to pay all costs incurred to People House at an hourly rate of $250/hour. In addition, a subpoena often indicates that the therapeutic alliance between client and therapist has entered into a dual relationship. In such a situations, we reserve the right to terminate therapy as our work may not continue to be supportive of the clients’ process.

Agreement and Acceptance

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

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

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Informed Consent for Teletherapy

Morgan Kautz Teletherapy Consent Form

Informed Consent for Teletherapy

Morgan Kautz, MA Candidate, Regis University

People House
3035 West 25th Avenue 
Denver, Colorado, 80211
‪(720) 443-3117‬
morgankautz@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.

,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.

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

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

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