COLORADO PSYCHOTHERAPY DISCLOSURE STATEMENT AND PSYCHOLOGICAL SERVICES AGREEMENT
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BEAU COUNSELING / DR. KRISTEN BEAU
Welcome to Beau Counseling. This document contains important information about my professional services and business policies. Please read it carefully and feel free to discuss any questions that you might have with me.
THERAPIST
I am a Registered Psychotherapist with the state of Colorado's Department of Regulatory Agencies (License #14129).  I earned a Masters degree in Contemplative Psychotherapy from Naropa University and a Doctorate degree in Existential- Humanistic Psychology from Saybrook University.  I am being directly supervised by a Licensed Psychologist in the state of Colorado, Casey Wolfington (License #3256).  The practice of licensed and unlicensed persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The Department of Regulatory Agencies can be reached at 1560 Broadway, Suite 1340, Denver, Colorado 80202.  There phone number is (303) 894-7766.
PSYCHOLOGICAL SERVICES
Participation in therapy can result in a number of benefits to you, your child and/or your family including improved relationships, resolution of specific problems, and reduction of feelings of distress. Working towards these benefits requires effort and active participation of you, your child, and/or the family. In order to be the most successful, you, your child, and/or your family will be asked to work on things that we discuss both during our sessions and at home. Always feel free to ask questions at any time. Since therapy involves discussing unpleasant feelings or events, you, your child and/or family may experience uncomfortable feelings such as sadness, worry and anger. Change can happen quickly but may also occur slowly.

You and/or your child are entitled to receive information from me about my methods and techniques used in therapy. Although it is difficult to predict the exact length of treatment, I can provide an estimate of the average evaluation and treatment duration for condition similar to your child's. You have the right to know about alternative types of treatment. You may seek a second opinion or terminate treatment at any time.

THERAPEUTIC RELATIONSHIP
The relationship with me is a professional and therapeutic relationship. In order to preserve this relationship, it is imperative that I not have any other type of relationship with your child or your family. Social and business relationships undermine the effectiveness of the therapeutic relationship. Gifts, bartering, and trading services are not appropriate and should not be shared between us. Sexual contact between therapist and client is not a part of any recognized psychotherapy. Sexual intimacy between client and therapist is illegal in Colorado and should be reported immediately to the State Grievance Board.
MEETINGS
I typically conduct an initial intake consultation where we can discuss your concerns and decide if I am the best person to provide the services you need in order to meet your and your child's treatment goals. If we decide to work together, I will usually schedule one 45-minute session per week at a mutually agreed upon time, although some sessions may be longer or more frequent. There is no charge for appointments cancelled by phone, 24 hours in advance of the scheduled time. Appointments cancelled less than 24 hours ahead of time are charged full fee. Please note that most insurance companies will NOT pay for cancellation fees, as such you will be responsible for this fee.
PROFESSIONAL FEES
Please review professional service rates:
Cash, check, Venmo, PayPal and **Credit Card are accepted forms of payment.

INDIVIDUAL THERAPY:
" Initial Individual Consultation: $180 / 60 minutes
" Individual Therapy:  $180 /50 minutes
" Individual Therapy: $270 / 90 minutes

FAMILY/COUPLES THERAPY:
" Initial Family/Couples Consultation: $200/ 60 minutes
" Family/Couples Therapy: $200 / 50 minutes
" Family/Couples Therapy: $300 / 90 minutes

OTHER:
" Group Therapy: $100 / group session
" Phone and Academic Consultations: $180 / 50 minutes
" Emergency/After-Hour Consultation: $180 / 50 minutes
" Weekend Intensives: $1500
" Psychedelic Medicine Journey: $2600 / Pre-Intention session 1 hour, medicine session 4-6 hours, post-integration session 1 hour

**Credit Card payments include a $3.00 per session service charge fee.
All Payments are through Ivy Pay or you may pay me directly via check/cash

Business Hours are Monday through Thursday 7 a.m. to 7 p.m. Fees are due in full at the end of each session. Beau Counseling currently accepts cash, check, Venmo, PayPal or credit card payment for services rendered. Credit Card payments include a $10.00 per session service charge fee (i.e., Individual Therapy is $180.00 / 45-50 minutes, however $183.00 will be charged to credit card). Cash, check payments do NOT include an extra service charge of $3.00.  Declined Credit Cards are subject to a $10.00 declined credit card fee. Checks that are returned will be assessed a $30.00 returned check fee to cover bank fees. Flexible payment options and sliding scale fees are available upon request.

In addition to weekly appointments, I charge an hourly rate for other professional services you may need. These may include report writing, telephone consultations lasting longer than 10 minutes, attendance at meetings/conferences (pre-authorized), preparation of records or treatment summaries, etc... If you or your child becomes involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge an hourly forensic fee for preparation and attendance at any legal proceedings.

If your account has been unpaid for more than 60 days, and arrangements for payment have not been agreed upon, I have the option of using legal means to secure payment. This may involve hiring a collection agency or legal services, which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a client's treatment is his or her name, the nature of the services provided, and the amount due. If such legal action becomes necessary, you will also be held responsible for any collection or legal costs, including attorney's fees, which may be necessary.
CONTACTING ME
I am often not immediately available by telephone. While in the office, I do not answer my phone when I am with a client. When I am unavailable, my telephone is answered by voicemail, which I monitor frequently. I will make every effort to return your call within one business day. If you are difficult to reach, please leave the best time to reach you. If I am unavailable for an extended period of time, I will provide you with contact information of a colleague. If you are unable to reach me and feel that you cannot wait for me to return your call, you may call 911 or go to the nearest emergency room and ask for the psychologist or psychiatrist on call.

You may feel free to e-mail and text me if you would like, however, it is important to note that e-mails and text messages are vulnerable to unauthorized access. Please use caution in sharing sensitive personal information when using electronic means. Also, I do not monitor this type of communication as regularly as voicemail, so please do not use for urgent matters.

It is important that you determine the level of emergency care that you would like to have with a therapist. My practice does not provide 24-hour care. In the event of an emergency, it may be necessary for you to contact another health provider. If this does not meet your needs, please let me know and I will provide you with the name of organizations and clinicians who provide 24-hour care.
HIPAA WAIVER: E-mail, Text & Other Electronic Communications
 (a)    Client acknowledges that neither Dr. Kristen Beau Howard, nor any mental health professional, counselor, clinical intern, or other individual associated with Beau Counseling (Beau and Company, LLC), (hereinafter referred to collectively as "the clinician") guarantees that communications with the clinician using electronic mail (" e-mail "), facsimile, video chat, instant messaging, and cellular telephone (phone calls or "text messaging") are secure or confidential methods of communications. Accordingly, Client expressly waives Group's and Physician's obligations under the Health Insurance Portability and Accountability Act of 1996(42 U.S.C. § 1320d et seq .), as amended by the Health Information Technology for Economic and Clinical Health Act of 2009, the Final Omnibus Rule of 2013, and all rules and regulations promulgated thereunder (collectively, " HIPAA "), and other state and federal laws and regulations applicable to the use, maintenance, and disclosure of Client-related information, to guarantee confidentiality with respect to correspondence using such means of communication. Client acknowledges that all such communications may become a part of Client's medical records maintained by the clinician.  Client also acknowledges that, depending on the Client's cell phone or other data plans, periodic communications sent by the clinician via text message, phone, and email, could potentially cause additional charges for Client under Client's cell phone or other data plan.  The client understands that they will be responsible for any associated charges. In the event that Client does not want to receive such periodic communications, Client agrees to notify the clinician in writing of his/her desire to be removed from such communications.
(b)    By providing Client's e-mail address to the clinician, Client authorizes the clinician to communicate with Client by e-mail regarding Client's "protected health information" (" PHI ") (as defined under HIPAA) and Client understands and agrees to the following:
(i)           E-mail is not necessarily a secure medium for sending or receiving PHI and, accordingly, any third party may gain access to such PHI;
(ii)         Although the clinician will make all reasonable efforts to keep e-mail communications confidential and secure, the clinician cannot assure or guarantee the absolute confidentiality of such e-mail communications;
(iii)        In the clinician's sole discretion, the clinician may include such e-mail communications with Client as part of Client's permanent medical record; and
(iv)         E-mail is not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation in which Client could reasonably expect to develop into an emergency, Client shall call 911 or the nearest hospital or emergency room, and follow the directions of emergency room personnel.
(c)   If Client does not receive a response to an e-mail message or text message within one (1) day, Client shall use another means of communication to contact the clinician. The clinician shall not be liable to Client for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Client as a result of technical failures, including, but not limited to the following:  (i) technical failures attributable to any internet service provider; (ii) power outages, failure of any electronic messaging software, or failure to properly address e-mail messages; (iii) failure of the clinician's computers or computer network, or faulty telephone or cable data transmission; (iv) any interception of e-mail communications by a third party; or (v) Client's failure to comply with the guidelines regarding use of e-mail or text message communications set forth herein.
(d)  By signature below, Client acknowledges that he/she fully understands the legal ramifications and that Client has had the opportunity to seek independent legal advice regarding the Psychological Services Agreement prior to execution.

CONFIDENTIALITY
In general, law protects the privacy of all communication between a client and a psychotherapist, and I can only release information about my work with you, your child and/or your family with your written permission. However, there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your or your child's treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it.

There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client's treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I must file a report with the appropriate state agency. If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or hospitalization for the client. If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members who can provide protection. Should a situation like this occur, I will make every effort to fully discuss it with you before taking any action.

Minors seeking therapy services should be aware that the law may provide parents the right to examine your treatment records. It is my policy to work with teens and their parents to identify to an agreement about what information can be shared and what information the teen would prefer to keep private.

In cases where a parent is seeking services for their child and the identified parents of the child are divorced, it is my policy to provide services to the child only if BOTH parents consent to mental health services. There are exceptions to this policy including situations in which a child has a protection order against a parent, a child has emancipation status, and/or a parent's parental rights has been suspended or terminated.  
AGREEMENT
I have been informed of my psychotherapist's degrees, credentials, and licensure status. I have read the preceding information and understand my child and family's rights as a client.

Your signature below indicates that you agree to abide by the terms outlined in this document during our professional relationship.
I hereby acknowledge that I have received a copy of the provider's Payment Policy: *
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