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Terms and Policy

Informed Consent
You are receiving psychotherapy from Peter J. Marsh, a licensed marriage family therapist license number MFT 0001265 in the State of Colorado, who holds a Masters of Arts degree in Marriage Family Therapy, at 4935 N 30th St Suite 140 Colorado Springs, CO 80919 719.425.1660.

General Information: The Mental Health Licensing section of the Division of Registrations regulates the practice of licensed or registered persons in the field of psychotherapy. The Board of Registered Psychotherapist Examiners can be reached at 1560 Broadway, Suite 1350, and Denver, Colorado 80202, (303) 894-7800. As to the regulatory requirements applicable to mental health professionals:

12-43-201. Definitions. As used in this article 43, unless the context otherwise requires:

"Board" includes the state board of psychologist examiners, the state board of social work examiners, the state board of licensed professional counselor examiners, the state board of marriage and family therapist examiners, the state board of registered psychotherapists, and the state board of addiction counselor examiners.
       "Certificate holder" means an addiction counselor certified pursuant to this article.
       "Certified addiction counselor" means a person who is an addiction counsel or certified pursuant to this article.
       "Dementia diseases and related disabilities" has the same meaning set forth in section 25-1-502 (2.5).
       "Director" means the director of the division of professions and occupations in the department of regulatory agencies.
       "Division" means the division of professions and occupations in the department of regulatory agencies.
       "Licensed addiction counselor" means a person who is an addiction counselor licensed pursuant to this article.
       "Licensed professional counselor" means a person who is a professional counselor licensed pursuant to this article.
       "Licensed social worker" means a person who:
       Is a licensed social worker or licensed clinical social worker; and Is licensed pursuant to this article.
       "Licensee" means a psychologist, social worker, clinical social worker, marriage and family therapist, licensed professional counselor, or         
        addiction counselor licensed pursuant to this article.
       "Marriage and family therapist" means a person who is a marriage and family therapist licensed pursuant to this article.
       "Professional relationship" means an interaction that is deliberately planned or directed, or both, by the licensee, registrant, or certificate  
        holder toward obtaining specific objectives.
       "Provisional license" means a license or certification issued pursuant to section 12-43-206.5.
       "Provisional licensee" means a person who holds a provisional license pursuant to section 12-43-206.5.
Mental Health Practice Act 4 of 74 2018
       "Psychologist" means a person who is a psychologist licensed pursuant to this article.
       "Psychotherapy" means the treatment, diagnosis, testing, assessment, or counseling in a professional relationship to assist individuals or  
        groups to alleviate behavioral and mental health disorders, understand unconscious or conscious motivation, resolve emotional, 
        relationship, or attitudinal conflicts, or modify behaviors that interfere with effective emotional, social, or intellectual functioning.           
        Psychotherapy follows a planned procedure of intervention that takes place on a regular basis, over a period of time, or in the cases of         
        testing, assessment, and brief psychotherapy, psychotherapy can be a single intervention. It is the intent of the general assembly that the  
        definition of psychotherapy as used in this article be interpreted in its narrowest sense to regulate only those persons who clearly fall    
        within the definition set forth in this subsection (9).

       "Registered psychotherapist" means a person:

             o   Whose primary practice is psychotherapy or who holds himself or herself out to the public as being able to practice psychotherapy for  

                  compensation; and

             o   Who is registered with the state board of registered psychotherapists pursuant to section 12-43-702.5 to practice psychotherapy in   

                  this state.

       "Registered psychotherapist" also includes a person who:

            o    Is a licensed school psychologist licensed pursuant to section 22-60.5-210 (1)(b), C.R.S.;

            o    Is practicing outside of a school setting; and

            o    Is registered with the state board of registered psychotherapists pursuant to section 12-43-702.5.

   "Registrant" means a psychologist candidate, marriage and family therapist candidate, or licensed professional counselor candidate registered pursuant to section 12-43-304 (7), 12-43-504 (5), or 12-43-603 (5), respectively, or a registered psychotherapist.

Generally speaking, the information provided by and to the client during therapy sessions is legally confidential and cannot be released without the client's consent. There are exceptions to this confidentiality, some of which are listed in section 12-43-218 of the Colorado Revised Statutesand the HIPAA Notice of Privacy Rights you were providedas well as other exceptions in Colorado and Federal law. For example, mental health professionals are required to report suspected child abuse to authorities. If a legal exception arises during therapy, if feasible, you will be informed accordingly. The Mental Health Practice Act (CRS 12-43-101, et seq.) is available at:

http://www.dora.state.co.us/mental-health/Statute.pdf.


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.


You are entitled to receive information from your therapist about the methods of therapy, the techniques used, the duration of your therapy (if known), and the fee structure. You can seek a second opinion from another therapist or terminate therapy at any time.

Counselingis a collaborative process between you and a counselor to work on areas of dissatisfaction in your life and assist you with life goals. For counseling to be most effective, it is important that you take an active role in the process. I will enter our relationship with optimism about our progress. Client can terminate counseling services at anytime.  If a client has not had a session after 60 days, then the counseling relationship is considered terminated unless client and therapist have agreed upon other arrangements.


Philosophy and Approach:   People experience problems, which result in forming beliefs about themselves, which are false causing negative emotions that impact their choices.  During the counseling process, I seek to validate people's experiences while helping them uncover the truth about their inherent value and worth in order to reframe their problems and discover solutions to them.  


As a Christian Therapist, I counsel from a Christian worldview and seek to honor Biblical principles in thedelivery of counseling services.  I adhere to the ethical code of the American Association of Marriage Family Therapists and established evidenced based therapeutic models within the field of psychology.  No client is ever refused professional services based on race, religion, gender, color, disability, national origin, socio-economic status, or sexual orientation.  This policy reflects my deep commitment to client self-determination.  I accept that the imposition of therapist values on a client is wrong.  


Confidentiality:As a Counselor in the State of Colorado, I am bound by the Colorado Title 12 Article 43-218 of the Colorado Revised Statutes. In accordancewith these rules, information obtained in thecounseling session or in written form willnotbe disclosed to any outside person(s) or agency without your written permissionexcept whensuchdisclosure is necessary to "protect you or someone else from imminent harm" or is otherwise legally requiredand/or allowed by law (such as abuse of a child, elder, or disabledperson or court order). If you are under 18,your parents or legal guardian(s) may have accessto your records andmay authorize release to otherparties.Furthermore,if you want your EAP or insurance to payfor all or part of your treatment, Imust be able to discuss your diagnosisand treatmentwith their representative.


Risks: In counseling, major life decisions aresometimes made, including decisions involvingseparation within families, development of other types ofrelationships, changing employmentsettings and changing lifestyles. The decisionsarea legitimate outcome of the counselingexperience as a result of an individual's calling into question many of their beliefs and values. Furthermore, symptoms may be intensified and the emotional experiencemay be too intense to deal withat this time. I will be available to discuss any of your assumptions or possible negative side effects in our work together.


Electronic TransmissionI cannot ensure the confidentiality of anyform of communication through electronic media. An employer advises you that any email sent to me via a computer in a work-place environment is legally accessible.


Telephone Sessions:  If an ongoing therapeutic relationship is established it is expected a face-to-face visit would occur.  By signing this Disclosure Statement, you accept full responsibility for future face to face visits.  Also, you understand that no recording of sessions is ever permitted and is illegal in most cases without consent.  You acknowledge that you are not recording, in any manner, your sessions with Peter Marsh.


Records: I am required bylaw to maintain records of eachtime we meet or talk on the phone.These records include a brief synopsis of the conversation along withany observations or plans for the next meeting. 


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 concerning parental responsibilities or parenting time in the best interests of the family's children.


A judge cansubpoena your records for a varietyof reasons, and if this happens,Imustcomply.Icanbecalledtotestify about the contents of the recordsand I must comply. Also, in orderto file for insurance reimbursement, I have to assign you adiagnosis. If you have anyquestions about this, please let meknow. I will certainly share any information with you that Iprovide to aninsurance provider.


Consultation: Information about you may be discussed in confidence, without revealing your identity, with other counseling professionals for the purposeof consultation and providing you the best possible service.


Time Parameters: Individual appointments are scheduled for 50-minute segments.Being late for an appointment by 20 minutes or more may require that you reschedule.

Fees and Paymentwill be collected at the time of service. I currently do not accept insurance but will provide a receipt for services rendered.  Fees charged for a 50-minute session is $110 any time over one hour will be billed in 30-minute increments of $55.  If there is an economic hardship fees may be waived or reduced depending on your income or circumstance.

Cancellation: If you find itnecessary to cancelan appointment, please contactme at 719-425-1660 or peter@elevensixcounseling.com at least 24 hours in advance. Cancellations with less than 24hours advance notice will be chargedthe full fee. The providermay also terminate counseling in the event the clienthas missed3 appointments without calling to cancel 24 hours prior to the scheduledappointment.

Emergencies:If an emergency situation for which you feel immediate attention is necessary, please contact emergency services (911) immediatelyor go to your nearest hospital emergency room. I will follow those emergency services withstandard counseling.  

Consent:  I do hereby seek and consent to take part in the treatment by the counselor named below.  I understand that developing a treatment plan with this therapist and regularly reviewing our work toward meeting the treatment goals are in my best interest.  I agree to play an active role in this process.  


I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist.  I am aware that I may seek a second opinion from a different counselor or stop my treatment with this therapist at any time.


I understand that any kind of sexual relationship between a therapist and client is completely inappropriate, a violation of the therapist's professional code of ethics and should be reported to the therapist's licensing board.


I certify that this form, including the statements on the limits of confidentiality, has been fully explained to me, that I have read it or had it read to me, and that I understand its contents. I certify that I have legal authority to give consent for the treatment of all minor children that are included in therapy.


I have read the preceding information, it has also been provided verbally, and I understand my rights as a client or as the client's responsible party

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Privacy Statement Notice of Privacy Rights
THIS NOTICE CONTAINS INFORMATION CONCERNING HOW CONFIDENTIAL MENTAL HEALTH TREATMENT INFORMATION CONCERNING YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY AND LET US KNOW ANY QUESTIONS THAT YOU MAY HAVE CONCERNING THIS NOTICE.

During the process of providing services to you, Peter Marsh will obtain and use mental health and medical information concerning you that is both confidential and privileged. Ordinarily this confidential information will be used in the manner that is described in this statement, and will not be disclosed without your consent, except for the circumstances described in the Notice.

I. USES AND DISCLOSURES OF PROTECTED INFORMATION

A. General uses and disclosures not requiring the Patient’s Consent. PETER MARSH will use and disclose protected health information in the following ways.

1. Treatment. Treatment refers to the provision, coordination, or management of mental health care and related services by one or more health providers. For example, PETER MARSH and staff involved with your care may use your information to plan your course of treatment and consult with other health care professionals or their staff concerning services needed or provided to you.

2. Payment. Payment refers to the activities undertaken by a health care provider to obtain or provide reimbursement for the provision of health care. For example, PETER MARSH and other health care professionals will use information that identifies you, including information concerning your diagnosis, services provided to you, dates of services, and services needed by you, and may disclose such information to insurance companies, to businesses that review bills for health care services and handle claims for payment of health care benefits in order to obtain payment for services. If you are covered by Medicaid, information may be provided to the State of Colorado’s Medicaid program, including but not limited to your treatment, condition, diagnosis, and services received.

3. Health Care Operations. Health Care Operations means activities undertaken by health insurance companies, businesses that administer health plans and companies that review bills for health care services in order to process claims for health care benefits. These functions include management and administrative activities. For example, such companies may use your health information in monitoring of service quality, staff training and evaluation, medical reviews, legal services, auditing functions, compliance programs, business planning and accreditation, certification, licensing and credentialing activities.

4. Contacting the Patient. PETER MARSH may contact you to remind you of appointments and to tell you about treatments or other services that might be of benefit to you.

5. Required by Law. PETER MARSH will disclose protected health information when required by law. This includes, but is not limited to: (a) reporting child abuse or neglect to the Department of Human Services or to law enforcement; (b) when court ordered to release information; (c) when there is a legal duty to warn of a threat that a patient has made of imminent physical violence, health care professionals are required to notify the potential victim of such a threat, and report it to law enforcement; (d) when a patient is imminently dangerous to himself/herself or to others, or is gravely disabled, health care professionals may have a duty to hospitalize the patient in order to obtain a 72-hour evaluation of the patient; and (e) when required to report a threat to the national security of the United States.

6. Health Oversight Activities. Your confidential, protected health information may be disclosed to health oversight agencies for oversight activities authorized by law and necessary for the oversight of the health care system, government health care benefit programs, and regulatory programs or determining compliance with program standards.

7. Crimes on the premises or observed by PETER MARSH or personnel. Crimes that are observed by PETER MARSH and staff that are directed toward staff, or occur on the premises will be reported to law enforcement.

8. Business Associates. Confidential health care information concerning you, provided to insurers or to plans for purposes or payment for services that you receive may be disclosed to business associates. For example, some administrative, clinical, quality assurance, billing, legal, auditing and practice management services may be provided by contracting with outside entities to perform their contracted tasks. Business associates are required to enter into an agreement maintaining the privacy of the protected health information released to them.

9. Research. Protected health information concerning you may be used with your permission for research purposes if the relevant provisions of the Federal HIPAA Privacy Regulations are followed.

10. Involuntary Patients. Information regarding patients who are being treated involuntarily, pursuant to law, will be shared with other treatment providers, legal entities, third party payers and others, as necessary to provide the care and management coordination needed in compliance with Colorado law.

11. Family Members. Except for certain minors, incompetent patients, or involuntary patients, protected health information cannot be provided to family members without the patient’s consent. In situations where family members are present during a discussion with the patient, and it can be reasonably inferred from the circumstances that the patient does not object, information may be disclosed in the course of that discussion. However, if the patient objects, protected health information will not be disclosed.

12. Emergencies. In life threatening emergencies PETER MARSH will disclose information necessary to avoid serious harm or death.

B. Patient Release of Information or Authorization. PETER MARSH and other health care professionals may not use or disclose protected health information in any way without a signed release of information or authorization. When you sign a release of information, or an authorization, it may later be revoked, provided that the revocation is in writing. The revocation will apply, except to the extent PETER MARSH has already taken action in reliance thereon.

II. YOUR RIGHTS AS A PATIENT
A. Access to Protected Health Information. You have the right to receive a summary of confidential health information concerning mental health services needed or provided to you. There are some limitations to this right, which will be provided to you at the time of your request, if any such limitation applies. To make a request, ask PETER MARSH for the appropriate request form.

B. Amendment of Your Record. You have the right to request that PETER MARSH or your health care professionals amend your protected health information. PETER MARSH is not required to amend the record if it is determined that the record is accurate and complete. There are other exceptions, which will be provided to you at the time of your request, if relevant, along with the appeal process available to you. To make a request, ask PETER MARSH for the appropriate request form.

C. Accounting of Disclosures. You have the right to receive an accounting of certain disclosures PETER MARSH has made regarding your protected health information. However, that accounting does not include disclosures that were made for the purpose of treatment, payment, or health care operation. In addition, the accounting does not include disclosures made prior to April 14, 2003. There are other exceptions that will be provided to you, should you request an accounting. To make a request, ask PETER MARSH for the appropriate request form.

D. Additional Restrictions. You have the right to request additional restriction on the use of disclosure of your health information. PETER MARSH does not have to agree to that request, and there are certain limits to any restriction, which will be provided to you at the time of your request. To make a request, ask PETER MARSH for the appropriate request form.

E. Alternative Means of Receiving Confidential Communications. You have the right to request that you receive communications of protected health information from PETER MARSH by alternative means or at alternative locations. For example, if you do not want PETER MARSH to mail bills or other materials to your home, you can request that this information be sent to another address. There are limitations to the granting of such requests, which will be provided to you at the time of the request process. To make a request, ask PETER MARSH for the appropriate request form.

F. Copy of this Notice. You have a right to obtain another copy of this Notice upon request.

III. ADDITIONAL INFORMATION
A. Privacy Laws. PETER MARSH is required by State and Federal law to maintain the privacy of protected health information. In addition, PETER MARSH is required by law to provide patients with notice of its legal duties and privacy practices with respect to protected health information. That is the purpose of this Notice.

B. Terms of the Notice and Changes to the Notice. PETER MARSH is required to abide by the terms of this Notice, or any amended Notice that may follow. PETER MARSH reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all protected health information that it maintains. When the Notice is revised, the revised Notice will be posted in PETER MARSH service delivery sites and will be available upon request.

C. Complaints Regarding Privacy Rights. If you believe PETER MARSH has violated your privacy rights, you have the right to complain to PETER MARSH management. Please submit a statement in writing addressed to PETER MARSH 5080 Mark Dabling Blvd, Colorado Springs, CO 80918 concerning your complaint and the basis for it. You also have the right to complain to the United States Secretary of Health and Human Services by sending your complaint to the Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 515F, HHH Building, Washington D.C., 20201. It is the policy of PETER MARSH that there will be no retaliation for your filing of such complaints.

D. Additional Information. If you desire additional information about your privacy rights with PETER MARSH please ask me any questions that you may have.

IV. CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS

A. The confidentiality of alcohol and drug abuse patient records maintained by PETER MARSH is protected by Federal law and PETER MARSH’s regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser unless:
1. The patient comments in writing;
2. The disclosure is allowed by a court order; or
3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

B. Violation of the Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations.

C. Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime. Disclosure may be made concerning any threat made by a patient to commit imminent physical violence against another person to the potential victim who has been threatened and to law enforcement.

D. Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.

V. EFFECTIVE DATE, THIS NOTICE IS EFFECTIVE FEBRUARY 1, 2012
I understand these disclosures. I have received a copy of this Disclosure Statement and Notice of Privacy rights.


PLEASE PRINT A COPY FOR YOUR RECORDS.
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