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Disclosure Statement

 

The State of Colorado and the Code of Ethics of the American Association of Marriage and Family Therapists require that you know the credentials of the professional you are seeing in therapy.  Please read this Disclosure Statement, sign and date the consent for treatment.  If you have any questions, please ask your therapist.  

 

Licenses/Certifications

 

Licensed Marriage & Family Therapist (CO #475)

Licensed Professional Counselor (CO #3609)

Licensed Marriage & Family Therapist (CA #M12992)

Certified Addictions Counselor (CAC III) (CO #7096)

AAMFT Clinical Supervisor, (AAMFT #86697)

Registered Play Therapist Supervisor (Association of Play Therapy # 98-040)

Education

Tennessee Temple University – BA- Psychology/Bible

California Graduate School – MA - Theology

Goddard College – MA – Counseling/Psychology

California Graduate School – Theology/Counseling

Colorado School for Family Therapy – CAC III

Colorado School for Family Therapy – AAMFT Clinical Supervision

Colorado School for Family Therapy – Play Therapy Certification Training

 

Professional Organizations

 

I am a clinical member and clinical supervisor of AAMFT (American Association of Marriage and Family Therapy).   I was president of a local chapter of CAMFT in California for two years, and was on the executive board of EDAP (Eating Disorders Awareness and Prevention, Inc.) for ten years.  I served as President of the Colorado Association of Marriage and Family Therapists.

 

Therapist of the Year presented by COAMFT

Co-Founder:  Second Wind Fund,

Woman of Achievement Los Angeles County

AAMFT National Award
2016 Colorado Community Health Hero of the Year

Regulatory Requirements Applicable to Mental Health Professionals

The practice of licensed or registered persons in the field of psychotherapy is regulated by the Division of Professions and Occupations. The regulatory boards can be reached at 1560 Broadway, Suite 1350, Denver, CO 80202, (303) 894-7800. The regulatory requirements for mental health professionals provide that 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-masters 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 1,000 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 listed in the State’s Database and is authorized by law to practice psychotherapy in Colorado, but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state.

Client Rights and Important Information

a.             You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy, and my fee. Please ask if you would like to receive this information.

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

c.             In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the Board that licenses, certifies, or registers the therapist.

d.             Generally speaking, information provided by and to a client in a professional relationship with a psychotherapist is legally confidential, and the therapist cannot disclose the information without the client’s consent. There are several exceptions to confidentiality, which include: (1) I am required to report any suspected incident of child abuse or neglect to law enforcement; (2) I am required to report any threat of imminent physical harm by a client to law enforcement and to the person(s) threatened; (3) I am required to initiate a mental health evaluation of a client who is imminently dangerous to self or to others, or who is gravely disabled, as a result of a mental disorder; (4) I am required to report any suspected threat to national security to federal officials; (5) I am required to report abuse of a senior, who is 70 years of age or older, which I believe has probably occurred, including institutional neglect, physical injury, financial exploitation, or unreasonable restraint; and (6) I may be required by Court Order to disclose treatment information. (7) I am required by law to report any threats against locations such as churches, schools, theatres, workplaces, etc. to law enforcement in which case confidentiality may be breached. (7) CRS 12-43-218 allows confidentiality to be breached if a mental health professional believes a client is a potential school shooter.

e.             When I am concerned about a client’s safety, it is my policy to request a Welfare Check through local law enforcement. In doing so, I may disclose to law enforcement officers information concerning my concerns. By signing this Disclosure Statement and agreeing to treatment with me, you consent to this practice, if it should become necessary.

f.             Under Colorado law, C.R.S. § 14-10-123.8, parents have the right to access mental health treatment information concerning their minor children, unless the court has restricted access to such information. If you request treatment information from me, I may provide you with a treatment summary, in compliance with Colorado law and HIPAA Standards.

g.             I agree not to record our sessions without your written consent; and you agree not to tape record a session or a conversation with me without my written consent.

h.          There may be times when I need to consult with a colleague or another professional about issues raised by clients in therapy.  Client confidentiality is still protected during consultation by me and the professional consulted.  Signing this disclosure statement gives me permission to consult as needed to provide professional services to you as a client.

i.           In marriage and family counseling, the therapist holds to a “no secrets” policy.  All members of the couple or family system are treated equally and “secrets” are not kept by the therapist. There is no differential or discriminatory treatment of family members.

j.              Your client records will be destroyed seven years after termination of psychotherapy pursuant to DORA Rules and the Colorado Mental Health Practice Act, CRS 12-43-218

k.             Any staff member and/or therapist acting on behalf of Marjorie Laird, LLC will be authorized to communicate with you by telephone, text message, email and mail. In spite of efforts to keep the contents of the telephonic or text communication confidential, due to the nature of certain types of telephones, such as cell phones or mobile phones operating on radio transmissions, the possibility exists that other parties may overhear the contents of the transmission.

Children and Adolescents

A child fourteen or younger seen in this office must have the signature of a parent.  In the case of divorce, the authorization must be signed by both parents or the court document presented giving sole custody.  When a client is 15 years of age or older, that client is the privilege holder for himself or herself.

 Disclosure Regarding Divorce and Custody Litigation

If you are involved in divorce or custody litigation, my role as a therapist is not to make recommendations to the court concerning custody or parenting issues. By signing this Disclosure Statement, you agree not to subpoena me to court for testimony or for disclosure of treatment information in such litigation; and you agree not to request that I write any reports to the court or to your attorney, making recommendations concerning custody. The court can appoint professionals, who have no prior relationship with family members, to conduct an investigation or evaluation and to make recommendations to the court concerning parental responsibilities or parenting time in the best interests of the family’s children.

Services

I provide non-emergency psychotherapeutic services by scheduled appointment.  If I believe your psychotherapeutic issues are above my level of competence, or outside of my scope of practice, I am legally required to refer, terminate or consult. If, for any reason, you are unable to contact me by telephone (303) 358-3377, and you are having a true emergency, please call 911 or go to the nearest hospital emergency room.

Insurance and Payment

I am on a number of managed care and EAP programs.  Additionally, many insurance companies refer to me as a provider.  I will work with your insurance carrier as a courtesy to you.  It is YOUR responsibility to contact your insurance company, EAP, or managed care company relative to eligibility and payment. All information about fees and payments are contained in the STATEMENT OF FEE POLICY which you will be requested to read and sign.

My fee is $90.00 per session for clinical services and any related paper work. 

If you have any questions or would like additional information, please feel free to ask during the initial session or anytime during the psychotherapy process.

 

 


 

 

 

 

 

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