Informed Consent/Therapy Professional Disclosure Statement

A Mental Health Therapy Disclosure Statement outlines all that potential therapy clients need to know regarding the regulations, licenses, fees, and more! Clients who begin therapy with Ampaw Psychotherapy and Consulting will be asked to sign a document that includes the information below.

AMPAW PSYCHOTHERAPY AND CONSULTING LLC

DENVER, COLORADO

PHONE NUMBER: 719-647-7855, EMAIL: JOSEPHINE@AMPAWPC.COM

EFFECTIVE DATE OF THIS NOTICE This notice went into effect on October 21, 2021. The most recent update made on March 27, 2023

Mandatory Disclosure/Informed Consent for Psychotherapy

General Information

Ampaw Psychotherapy and Consulting LLC is an individually owned private practice and consulting firm focused on working with individuals, couples, families, and professionals from a strength-based, systemic or relational focus generally.  The approach may be adjusted on a case-by-case basis.

Josephine Ampaw is available for therapy via telehealth and in person at 8751 E Hampden Avenue STE B-9 Denver, CO 80230. Josephine Ampaw earned her Bachelor of Arts degree in Feminist Studies with a minor in History from the University of California, Santa Barbara in 2017 and completed her Master of Social Work and Master of Arts in Curriculum & Instruction at the University of Denver in 2020-2021. Josephine is also pursuing a marriage and family therapy certificate (MFTC) from Denver Family Institute and will be finishing training in June 2022.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

Confidentiality

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

  1. If a client threatens or attempts to die by suicide or otherwise conducts him/her/them self in a manner in which there is a substantial risk of incurring serious bodily harm.

  2. If a client threatens grave bodily harm or death to another person.

  3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years old.

    PLEASE NOTE:  Child abuse refers to any child abuse you discuss in therapy or that is observed.  This includes illegal sexual contact between two minors, or abuse of children outside your family.  I am mandated to report suspected child abuse. For more information regarding mandatory reporting, please visit: https://co4kids.org/mandatory-reporters.

  4. Suspicions as stated above in the case of an elderly person(over the age of 65 years old) who may be subjected to these abuses.

  5. Suspected neglect of the parties named in items #3 and # 4.

  6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

  7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally, I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

NO RECORDING - In order to preserve the vulnerability and openness necessary for effective therapy to occur, neither client nor therapist will record therapy sessions at any time for any reason unless otherwise discussed and approved by both parties in writing

Regulation of Psychotherapists

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 regulatory boards can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.  The regulatory requirements for mental health professionals provide that a Licensed Clinical Social Worker, a Licensed Marriage and Family therapist and a Licensed Professional Counselor must hold a Master’s degree in their profession and have two years of post-masters supervision.  A Licensed Psychologist must hold a Doctorate degree in psychology and have one year of post-doctoral supervision.  A Licensed Social Worker must hold a Master’s degree 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 Registered Psychotherapist is 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 registration from the state.

Client Rights and Important Information

a. You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy (if I can determine it), and my fee structure. Please ask if you would like to receive this information.

b. You can seek a second opinion from another therapist or terminate therapy at any time.

c. In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the Department of Regulatory Agencies, Mental Health Section.

d. Generally speaking, information provided by and to a client in a professional relationship with a psychotherapist is legally confidential and the therapist cannot disclose the information without the client’s consent.  There are several exceptions to confidentiality which include: (1) I am required to report any suspected incident of child abuse or neglect to law enforcement; (2) I am required to report any threat of imminent physical harm by a client to law enforcement and to the person(s) threatened; (3) I am required to initiate a mental health evaluation of a client who is imminently dangerous to self or to others, or who is gravely disabled as a result of a mental disorder; (4) I am required to report any suspected threat to national security to federal officials; (5) I may be required by Court Order to disclose treatment information; and (6) I am required to report any suspected incident of elderly abuse or neglect to law enforcement

e. Under Colorado law, C.R.S.§14-10-123.8, parents have the right to access mental health treatment information concerning their minor children, unless the court has restricted access to such information.  If you request treatment information from me, I may provide you with a treatment summary, in compliance with Colorado law and HIPPA Standards.

f. Records regarding the treatment of adults will be kept for seven (7) years after treatment ends or following last session, but records may not be kept after seven years. Records for treatment of minors will be kept for seven (7) years, commencing on the last date of treatment or when the minor reaches 18 years of age, whichever comes later, but in no event am I required to keep these records for longer than 12 years.

LIMIT OF SERVICES AVAILABLE:  Ampaw Psychotherapy and Consulting LLC does not provide emergency and after-hours services.  If you find yourself in a life-threatening situation and are unable to contact Josephine Ampaw, you agree to take the necessary steps to keep yourself safe, up to and including calling 911 or going to the emergency room (at your cost) if necessary.

I do not provide medications, psychiatric services, or psychological testing.

***If you think you are having a mental health emergency please call 911 or go to the nearest emergency room. You can contact the Colorado Crisis Support Line at 1-844-493-8255 or text “TALK” to 38255 to speak to someone 24 hours per day, 7 days per week.

If you are involved in a divorce or custody litigation, you need to understand that my role as a therapist is not to make recommendations for the court concerning custody or parenting issues or to testify in court concerning opinions on issues involved in the litigation. By signing this disclosure statement, you agree not to call me as a witness in any such litigation. Experience has shown that testimony by therapists in domestic dispute cases causes damage to the clinical relationship between a therapist and client. Only court-appointed experts, investigators, or evaluators can make recommendations to the court on disputed issues concerning parental responsibilities and parenting plans.

No Surprises Act

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.

You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

About the therapist

I am a Licensed Clinical Social Worker (LCSW) and Marriage and Family Therapist Candidate (MFTC). I am under the supervision of Janna Phillips, LCSW, LMFT, LAC as I work towards licensure in Marriage & Family Therapy(LMFT) and Addictions Counseling (LAC). If you have any concerns you do not feel comfortable addressing with me directly, please email my supervisor Janna Phillips at janna@jannaphillipsllc.com. If the therapist were to have an unforeseen extended leave or circumstance, clients will be informed through the therapist’s supervisor.