INTRODUCTORY PAPERWORK

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CLIENT RIGHTS DISCLOSURE STATEMENT
(Please read this statement and sign below):

The Statement below is information about your rights as a client that each therapist is mandated by law to provide to clients.  Your signature below indicates that you have read and understand your rights as a client as well as understand and the “Preliminary Information” about the process and structure of psychotherapy.

Acknowledgement:   Psychotherapy involves risks and responsibilities for client and therapist alike.  A client shows great courage to open herself or himself to self examination and growth in the presence of another human being.  It is the responsibility of the therapist to honor and respect each client and to render the best possible service as understood and agreed to by both client and therapist. 

“The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The Board of Social Work Examiners can be reached at 1560 Broadway, Suite 1350, Denver Colorado 80202, or by phone at (303) 894-7756.

As to the regulatory requirements applicable to mental health professionals: in their profession, a Licensed Clinical Social Worker (LCSW) must hold a masters degree in social work and have two years of post masters supervision.

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

In professional relationships, sexual intimacy is never appropriate and should be reported to the licensing board at the address above.

PRIVILEGED COMMUNICATIONS: Information provided by a client during therapy sessions is legally confidential and cannot be released without client consent in the case of social workers, except as provided by Section 12-43-18of the Colorado Revised Statutes, and other legal obligations as described
below..

THERAPIST’S LEGAL OBLIGATION: There are some situations in which therapists are required to take actions they believe necessary to attempt to protect others from harm, in which case, some information about the client’s treatment may have to be released. These situations are unusual, and include the following:

If there is reasonable cause to know or suspect that a child has been subjected to abuse or neglect, or if the therapist has observed a child being subject to circumstances or conditions that would reasonably result in abuse or neglect, the law requires that a report be filed by the therapist with the appropriate governmental agency. Once such a report is filed, the therapist may be obligated to provide further information.

If there is reason to believe that any at-risk adult has been or is in imminent danger of being mistreated, self neglected, or financially exploited, the law requires the therapist to file a report with the appropriate governmental agency. Once such a report is filed, the therapist may be obligated to provide further information.

If a client communicates serious threat of immanent harm to her or himself and /or against a specific person or persons, the therapist must make every effort to notify such person, and/or appropriate law enforcement agency, and /or take other appropriate action, including seeking hospitalization of the client.”.

Further, on occasion, a therapist may be subpoenaed by the courts to testify, and on very rare occasions, information may be released to the Social Work Licensing Board in the event of a grievance filed by a client. 

In addition, a client’s identity may be revealed to appropriate persons regarding payments in default. Other than in those situations, a client can expect absolute confidentiality about the nature of the work being done, or even the fact of the client’s involvement in therapy.  

“12.43.214(2) CRS: If a client is a child consenting to mental health services pursuant to Section 27-10-103, CRS, disclosure will be made to the child. If a client is a child whose parent or legal guardian consenting to mental health services, disclosure will be made to that person.”

Other than for the above exceptions, before any information can be shared with others, clients complete a written and signed specific release of information authorizing the sharing of information with specific persons or agencies.



Client Signature________________________________________________ Date ____________

Client Signature________________________________________________ Date ____________

Witness Signature______________________________________________ Date ____________




David A. Yeats M.S.W., L.C.S.W.
Psychotherapy and Consultation Services
350 Broadway, Suite 102
Boulder Colorado 80305
(303) 335.9170
www.DavidAYeats.com
DAYeatsMSW@Hotmail.com
Colorado License # 989213   EIN 84-1253608 NPI 1578702254


CLIENT INFORMATION
Please provide the following information for each individual:

Name ________________________________________________ Today’s Date ___________________
   Date of Birth _______________ Social Security Number ____________________________
Referred by: __________________________________________________________________________

Email Address ________________________________________________________________________
                   Home Phone _______________________Work Phone _________________________________
                   Cell Phone _____________________________ Other Phone __________________________________

                   Street Address _______________________________________________________________________
                   City __________________________________________ State __________ Zip ___________________
                   Mailing Address (if different) ____________________________________________________________
                   City __________________________________________ State __________ Zip ___________________

                   Employer Name ______________________________________________________________________
                   Employer Address ____________________________________________________________________
                   City __________________________________________ State __________ Zip ___________________

                   Credit Card Information (if paying by CC):    __
                   Name (as on card) ___________________________ Card #: __________________________________
                   Exp. Date (Month/Year):  ________    3 (or 4)-digit code _________   Zip on Card __________         


If you are currently involved in any other treatment, including treatment for psychotherapy (individual, couple, or group), psychiatry or medication management, relevant other medical conditions, pain management, acupuncture, chiropractics, etc, please indicate the names of each clinician and the purpose of treatment. (At some point, it may be useful to talk with other providers, and you may be asked to sign a release).

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________


If you are currently taking any prescribed psychiatric medication, please list med, prescribing physician, dosage and purpose.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________



David A. Yeats M.S.W., L.C.S.W.
Psychotherapy and Consultation Services
350 Broadway, Suite 102
Boulder Colorado 80305
(303) 335.9170
www.DavidAYeats.com
DAYeatsMSW@Hotmail.com
Colorado License # 989213   EIN 84-1253608 NPI 1578702254


Authorization for Release of Information

At times it may be necessary or useful to either give information to or receive information from individuals or agencies with whom a client is or has been involved, in order to coordinate and support successful therapy.  This exchange of information must be authorized by the client in writing.  This written authorization serves to document client knowledge and agreement to exchanging information.

I, __________________________________________, (client name),  whose date of birth is __________________,

and whose social security number is _______________________, do hereby authorize David Yeats MSW, LCSW, to

                                                         [  ] give information to, and/or
                                                         [  ] receive information from:

Name of Individual or Agency _______________________________________________________________________________________________

Relationship to Client _______________________________________________________________________________________________

Address _______________________________________________________________________________________________

Phone Number(s) ________________________________________________________________________________

Any exceptions should be noted here: _______________________________________________________________

_______________________________________________________________________________________________

By signing below I authorize this exchange of information, good for one year from the date below.  I understand that
I can revoke this release at any time.  I also acknowledge that a fax or email of this Authorization shall be as valid
as the original.


Client Signature _________________________________________________ Date ____________________________

Therapist Signature________________________________________________________________________________