Disclosures:

You are entitled to the consent requirements outlined under 2 CO ADC 502-1:21.170.4.

The confidentiality of your individual records, including all medical, mental health, substance use, psychological, and demographic information shall be protected with the applicable state and federal laws and regulations, as provided under 2 CO ADC 502-1:21.170.2.

You understand that your mental health records may not be maintained after the seven-year period for filing a complaint pursuant to Colorado Rev. Stat. 12-245-226 (1)(a)(II)(A).

You further understand, in accordance with Colorado Rev. Stat. 12-245-216:

1. You are entitled to receive information about the methods of therapy, the techniques used, the duration of therapy, if known, and the fee structure;
2. You may seek a second opinion from another therapist or may terminate therapy at any time;
3. 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 (located at the right).
4. The information provided by youduring therapy sessions is legally confidential in the case of individuals licensed, certified, or registered pursuant to this article 245, except as provided in section 12-245-220 and except for certain legal exceptions that will be identified by the licensee, registrant, or certificate holder should any such situation arise during therapy.

If an unlicensed psychotherapist is involved in your care, you understand that such provider is a psychotherapist 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.

You have been provided in writing the following information regarding your provider:

• The name, business address, and business phone number of the licensee, registrant, or certificate holder

You understand the below explanation of the levels of regulation applicable to mental health professionals under this article 245 and the differences between licensure, registration, and certification, including the educational, experience, and training requirements applicable to the particular level of regulation.

• A Registered Psychotherapist is a psychotherapist 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.
• A Certified Addiction Counselor I (CAC I) must be a high school graduate or equivalent, complete required training hours and 1,000 hours of supervised experience.
• A Certified Addiction Counselor II (CAC II) must be a high school graduate or equivalent, complete the CAC I requirements, and obtain additional required training hours, 2,000 additional hours of supervised experience, and pass a national exam.
• A Certified Addiction Counselor III (CAC III) must have a bachelor’s degree in behavioral health, complete CAC II requirements, and complete additional required training hours, 2,000 additional hours of supervised experience, and pass a national exam.
• A Licensed Addiction Counselor must have a clinical master’s degree, meet the CAC III requirements, and pass a national exam. • A Licensed Social Worker must hold a master’s degree from a graduate school of social work and pass an examination in social work.
• A Licensed Clinical Social Worker must hold a master’s or doctorate degree from a graduate school of social work, practiced as a social worker for at least two years, and pass an examination in social work. Page 2 of 3
• 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 Licensed Marriage and Family Therapist must hold a master’s or doctoral degree in marriage and family counseling, have at least two years post-master’s or one year post-doctoral practice, and pass an exam in marriage and family therapy.
• A Licensed Professional Counselor must hold a master’s or doctoral degree in professional counseling, have at least two years post-master’s or one year postdoctoral practice, and pass an exam in in professional counseling.
• A Licensed Psychologist must hold a doctorate degree in psychology, have one year of post-doctoral supervision, and pass an examination in psychology.