This form is called a Consent for Services (the “Consent”). Your therapist (“Provider”) has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Provider. This mandatory disclosure statement is for Christy Sorden, as therapist for Christy Sorden Counseling, PC. Located at 7035 Campus Drive #806, Colorado Springs, CO 80920. Phone number 719-351-3155. Colorado License LPC 4835, Arizona License LPC-22531.
– 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.
– 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.
Christy Sorden obtained a Master’s Degree in Counseling and Human Services through the University of Colorado at Colorado Springs, CO has at least two years of post-master’s practice, passed an exam in professional counseling, and met all of the DORA requirements in education, training, and experience to become a Licensed Professional Counselor (LPC) #4835 issued 8/2007 and AZ LPC- 22531 issued on 10/19/2023. Christy also meets the criteria for the National Board Certified Counselor (NBCC) issued 1/2005. Christy has completed the basic training in Eye Movement Desensitization Reprocessing from the EMDR Institute as well as the basic and advanced training in Reality Therapy, and Choice Theory through the William Glasser Institute. Christy is also trained in Applied Suicide Intervention Skills Training (ASIST). You are entitled to receive information about the method of therapy, techniques used, anticipated duration of treatment, and fees to be charged at any time you so request. You may seek a second opinion from another therapist or may terminate therapy at any time.
The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Professions and Occupations. The Board of Colorado Department of Regulatory Agencies can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.
THE THERAPY PROCESS
Therapy is a collaborative process where you and your Provider will work together on equal footing to achieve goals that you define. This means that you will follow a defined process supported by scientific evidence, where you and your Provider have specific rights and responsibilities. Therapy generally shows positive outcomes for individuals who follow the process. Better outcomes are often associated with a good relationship between a client and their Provider. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit.
Therapy begins with the intake process. First, you will review your Provider’s policies and procedures, talk about fees, identify emergency contacts, and decide if you want health insurance to pay your fees depending on your plan’s benefits. Second, you will discuss what to expect during therapy, including the type of therapy, the length of treatment, and the risks and benefits. If your Provider is practicing under the supervision of another professional, your Provider will tell you about their supervision and the name of the supervising professional. Third, you will form a treatment plan, including the type of therapy, how often you will attend therapy, your short- and long-term goals, and the steps you will take to achieve them. Over time, you and your Provider may edit your treatment plan to be sure it describes your goals and steps you need to take. After intake, you will attend regular therapy sessions at your Provider’s office or through video, called telehealth. Participation in therapy is voluntary – you can stop at any time. At some point, you will achieve your goals. At this time, you will review your progress, identify supports that will help you maintain your progress, and discuss how to return to therapy if you need it in the future.
IN-PERSON VISITS & SARS-CoV-2 (“COVID-19”)
When guidance from public health authorities allows and your Provider offers, you can meet in-person. If you attend therapy in-person, you understand:
• You can only attend if you are symptom-free (For symptoms, see: https://www.cdc.gov/
• If you are experiencing symptoms, you can switch to a telehealth appointment.
• You must follow all safety protocols established by the practice, including:
• Following the check-in procedure;
• Washing or sanitizing your hands upon entering the practice;
• Adhering to appropriate social distancing measures;
• Wearing a mask, if required;
• Telling your Provider if you have a high risk of exposure to COVID-19, such as through school, work, or commuting; and
• Telling your Provider if you or someone in your home tests positive for COVID-19.
• Your Provider will never share details about your visit. Your ability to meet in person could change with minimal or no notice. By signing this Consent, you understand that you could be exposed to COVID-19 if you attend in-person sessions. If a member of the practice tests positive for COVID-19, you will be notified. If you have any questions, or if you want a copy of this policy, please ask.
TELEHEALTH SERVICES
To use telehealth, you need an internet connection and a device with a camera for video. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option. There are some risks and benefits to using telehealth:
• Risks
• Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Provider carefully vets any telehealth platform to ensure your information is secured to the appropriate standards.
• Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Provider will follow the backup plan that you agree to prior to sessions.
• Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and your Provider will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services.
• Benefits
• Flexibility. You can attend therapy wherever is convenient for you.
• Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.
• Recommendations
• Make sure that other people cannot hear your conversation or see your screen during sessions.
• Do not use video or audio to record your session unless you ask your Provider for their permission in advance.
• Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.
CONFIDENTIALITY
Your Provider will not disclose your personal information without your permission unless required by law. If your Provider must disclose your personal information without your permission, your Provider will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions.
• Your Provider may speak to other healthcare providers involved in your care.
• Your Provider may speak to emergency personnel.
• If you report that another healthcare provider is engaging in inappropriate behavior, your Provider may be required to report this information to the appropriate licensing board. Your Provider will discuss making this report with you first, and will only share the minimum information needed while making a report. If your Provider must share your personal information without getting your permission first, they will only share the minimum information needed. There are a few times that your Provider may not keep your personal information confidential.
• If your Provider believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement. The term specific, credible threat is defined by state law. Your Provider can explain more if you have questions.
• If your Provider has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.
• If your Provider believes that you are at imminent risk of harming yourself, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your Provider will work with you to discuss other options to keep you safe.
You have the right to confidential treatment. The information provided by the client during therapy sessions is legally confidential in the case of licensed marriage and family therapists, social workers, professional counselors, and psychologists; licensed or certified addiction counselors; and registered psychotherapists, except as provided in § 12-43-218 and except for certain legal exceptions that will be identified by the licensee, should any such situation arise during therapy. There are exceptions to this confidentiality, some of which are listed in section 1243218 of the Colorado Revised Statutes, and the HIPAA Notice of Privacy Rights you were provided, as well as other exceptions in Colorado and Federal law. Confidentiality is maintained unless you become an imminent danger to yourself or another person, and then only minimal information is shared to facilitate your or another’s safety. Confidentiality also will be waived automatically in cases involving child abuse, child sexual abuse, grave emotional disability or criminal behavior. Every effort will be made to minimize the data shared with other professionals or authorities, including your Primary Care Physician. You have the right to terminate treatment at any time and you also may request a second opinion at any time.
Disclosure Regarding Divorce, Custody Litigation, and Court Involvement.
As a Licensed Professional Counselor (LPC), my primary role is to provide therapeutic services. However, there may be situations where I am requested or required to participate in legal proceedings related to your case. This disclosure outlines the fees and terms associated with any court-related involvement. If you are involved in divorce, custody litigation, or court involvement my role as the therapist is not to make recommendations to the court concerning custody or parenting issues. Any statement I might make could be seen as biased in your favor because we have a therapy relationship, and any testimony might affect our therapy, and I must put this relationship first.
Court-Related Services May Include:
- Testimony in court (including depositions)
- Preparation of reports or affidavits
- Consultation with attorneys
- Time spent on legal correspondence, preparation, and phone calls
- Travel time to and from court or deposition locations
Fee Schedule for Legal Services:
- Court Testimony: $600 per hour (minimum of 2 hours billed in advance)
- Depositions: $400 per hour (minimum of 2 hours billed in advance)
- Record Preparation and Report Writing: $300 per hour
- Consultation with Attorneys: $300 per hour
- Travel Time: $100 per hour (charged for travel to and from the location)
Billing Policies:
- All fees for court appearances, depositions, and legal consultation are due in full prior to the scheduled date.
- A retainer may be required to reserve the counselor’s time for legal matters.
- The client is responsible for any additional fees not covered by the retainer, which will be billed following the legal proceedings.
Cancellations:
- A minimum notice of 7 days is required for the cancellation of any court appearance or deposition. Failure to provide adequate notice will result in a charge for the full scheduled time.
Please note that I do not voluntarily engage in legal matters, and my participation is generally limited to instances where I am compelled by a court order or subpoena. If you anticipate the need for my involvement in legal proceedings, please inform me as early as possible so we can discuss the appropriate steps.
RECORD KEEPING
Your Provider is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by TherapyNotes. TherapyNotes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. TherapyNotes keeps records of all log-ins and actions within the system.
COMMUNICATION
You decide how to communicate with your Provider outside of your sessions. You have several options:
Texting/Email
• Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.
Secure Communication
• Secure communications are the best way to communicate personal information, though no method is entirely without risk. Your Provider will discuss the options available to you. If you decide to be contacted via non-secure methods, your Provider will document this in your record.
Social Media/Review Websites
• If you try to communicate with your Provider via these methods, they will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy.
• Your provider may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider on any platform, they will not follow you back.
• If you see your Provider on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing in other places without your knowledge.
If keeping your appointments becomes a problem and we are not able to resolve this then I do reserve the right to charge you personally for your missed appointment. In an emergency, you may call the crisis line at 844-493-8255 or text 38255.
I have read the above disclosures prior to my appointment, as well as reviewed verbally with Christy Sorden at the time of the initial appointment.
FEES AND PAYMENT FOR SERVICES
You may be required to pay for services and other fees. You will be provided with these costs prior to beginning therapy and should confirm with your insurance if part or all of these fees may be covered. You should also know about the following:
• No-Show and Late Cancellation Fees
• If you are unable to attend therapy, you must contact your Provider before your session. Otherwise, you may be subject to fees outlined in your fee agreement. Insurance does not cover these fees. If an appointment is made, please give 24 hours cancellation notice. When you accept an appointment time, you are making a commitment to your therapist to be there on that scheduled day and time.
• Balance Accrual
• Full payment is due at the time of your session. If you are unable to pay, tell your Provider. Your Provider may offer payment plans or a sliding scale. If not, your Provider may refer you to other low- or no-cost services. Any balance due will continue to be due until paid in full. Past-due personal accounts will be charged a finance charge of 1.5% monthly. Returned checks will be assessed at $15.00 plus any bank charges. Long overdue or delinquent accounts will be turned over to an attorney or collection agency for collection and/or legal proceedings. You will be responsible for the legal fees entailed in that process. Your name, address, employment, phone, and balance owed will be provided to the collection agency or attorney.
• Administrative Fees
• Your Provider may charge administrative fees for writing a letter or report at your request; consulting with another healthcare provider or other professional outside of normal case management practices; or for preparation, travel, and attendance at a court appearance. These fees are listed in the fee agreement. Payment is due in advance.
• Insurance Benefits
• Before starting therapy, you should confirm with your insurance company if:
• Your benefits cover the type of therapy you will receive;
• Your benefits cover in-person and telehealth sessions;
• You may be responsible for any portion of the payment; and
• Your Provider is in-network or out-of-network.
• Sharing Information with Insurance Companies
• If you choose to use insurance benefits to pay for services, you will be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share it to act on your behalf, comply with federal or state law, or complete administrative work.
• Covered and Non-Covered Services
• When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost of therapy. You are responsible for any part of this cost not covered by insurance, such as deductibles, copays, or coinsurance. You may also be responsible for any services not covered by your insurance.
• When your Provider is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Provider; however, all fees will be due at the time of your session to your Provider. Your Provider will tell you if they can help you file for reimbursement from your insurance company. If your insurance company decides that they will not reimburse you, you are still responsible for the full amount.
• Payment Methods
• The practice requires that you keep a valid credit or debit card on file. This card will be charged for the amount due at the time of service and for any fees you may accrue unless other arrangements have been made with the practice ahead of time. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges.
EXPLANATION OF FEES
$220.00 Initial Session
$200.00 Individual Session
$180.00 Family Session with or without patient
$85.00 Group Therapy
No-Shows and late cancellations (less than 24 hour notice) are billed $75.
$75.00 minimum charge for letter writing
$50.00 minimum charge for file copying
$100.00 per hour for review of records and documents
Court Costs (payable in advance)
Court Testimony: $600 per hour (minimum of 2 hours billed in advance)
- Depositions: $400 per hour (minimum of 2 hours billed in advance)
- Record Preparation and Report Writing: $300 per hour
- Consultation with Attorneys: $300 per hour
- Travel Time: $100 per hour (charged for travel to and from the location)
SURPRISE/BALANCE BILLING DISCLOSURE FORM
Surprise Billing – Know Your Rights
Beginning January 1, 2020, Colorado state law protects you* from “surprise billing,” also known as “balance billing.” These protections apply when:
You receive covered emergency services, other than ambulance services, from an out-of-network provider in Colorado, and/or You unintentionally receive covered services from an out-of-network provider at an in-network facility in Colorado What is surprise/balance billing, and when does it happen?
If you are seen by a health care provider or use services in a facility or agency that is not in your health insurance plan’s provider network, sometimes referred to as “out-of-network,” you may receive a bill for additional costs associated with that care. Out-of-network health care providers often bill you for the difference between what your insurer decides is the eligible charge and what the out-of-network provider bills as the total charge. This is called “surprise” or “balance” billing.
When you CANNOT be balance-billed:
Emergency Services
If you are receiving emergency services, the most you can be billed for is your plan’s in-network cost-sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be balance-billed for any other amount. This includes both the emergency facility where you receive emergency services and any providers that see you for emergency care.
Nonemergency Services at an In-Network or Out-of-Network Health Care Provider
The health care provider must tell you if you are at an out-of-network location or at an in-network location that is using out-of-network providers. They must also tell you what types of services that you will be using may be provided by any out-of-network provider.
You have the right to request that in-network providers perform all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is not available. In this case, the most you can be billed for covered services is your in-network cost-sharing amount, which are copayments, deductibles, and/or coinsurance. These providers cannot balance bill you for additional costs.Additional Protections
Your insurer will pay out-of-network providers and facilities directly.
Your insurer must count any amount you pay for emergency services or certain out-of-network services (described above) toward your in-network deductible and out-of-pocket limit.
Your provider, facility, hospital, or agency must refund any amount you overpay within sixty days of being notified.
No one, including a provider, hospital, or insurer can ask you to limit or give up these rights.
If you receive services from an out-of-network provider or facility or agency OTHER situation, you may still be balance billed, or you may be responsible for the entire bill. If you intentionally receive nonemergency services from an out-of-network provider or facility, you may also be balance billed.If you want to file a complaint against your healthcare provider, you can submit an online complaint by visiting this website: https://www.colorado.gov/
pacific/dora/DPO_File_ Complaint. If you think you have received a bill for amounts other than your copayments, deductible, and/or coinsurance, please contact the billing department, or the Colorado Division of Insurance at 303-894-7490 or 1-800-930-3745.
*This law does NOT apply to ALL Colorado health plans. It only applies if you have a “CO-DOI” on your health insurance ID card.
Please contact your health insurance plan at the number on your health insurance ID card or the Colorado Division of Insurance with questions.COMPLAINTS
If you feel your Provider has engaged in improper or unethical behavior, you can talk to them, or you may contact the licensing board that issued your Provider’s license, your insurance company (if applicable), or the US Department of Health and Human Services. Sexual contact between client and therapist is not part of any recognized therapy. Sexual intimacy between client and therapist is illegal in Colorado and should be reported to the Grievance Board.