Rocky Mountain Thrive Psychotherapy, PLLC

PURPOSE OF THIS DOCUMENT

The following information is provided to help you determine if what I offer as a mental health therapist meets your needs as a client. This document contains important information about my therapeutic approach, my education, my fees, and your rights as a client, including your rights regarding your private health information.

Please read this document carefully and ask any questions that help you fully understand the contents of this disclosure statement and agreement for services. Your signature at the end of this document confirms your consent to participate in services under the terms described here.

MY EDUCATION, TRAINING, AND EXPERIENCE

[Insert clinician-specific education section here. Include degrees, institutions, and years.]

• Degree: [Master of Arts / Master of Social Work / etc.] in [Field]
• Institution: [University Name]
• Additional degrees: [List any]
• Colorado License: [License type] #[License number]
• Supervision (if applicable): Supervised by [Supervisor Name], [Credentials], License #[Number]

The practice of licensed and registered persons in the field of psychotherapy in Colorado is regulated by the Colorado Division of Professions and Occupations (DORA). DORA may be contacted at:

Colorado Division of Professions and Occupations — Mental Health Licensing Section
1560 Broadway, Suite 1350, Denver, CO 80202
Phone: (303) 894-7800 | Email: dora_dpo_licensing@state.co.us
Website: dpo.colorado.gov

THERAPEUTIC ORIENTATION & PRACTICE MODALITY

[Insert clinician-specific therapeutic orientation here.]

My foundational clinical orientation encompasses a trauma-informed approach. I use a strengths-based framework and somatic approaches. My therapeutic approach may incorporate evidence-based practices including:

• Cognitive Behavioral Therapy (CBT)
• Acceptance and Commitment Therapy (ACT)
• EMDR Therapy
• Mindfulness-Based Approaches
• Narrative Therapy
• Emotion-Focused Therapy (EFT)
• Solution-Focused Therapy
• Psychodynamic Therapy

I work collaboratively with each client to explore which modality and tools will best support their goals. Your treatment plan will be individualized and reviewed regularly.

TELEHEALTH SERVICES IN COLORADO

Rocky Mountain Thrive provides all services via telehealth only. All services are delivered in compliance with the Colorado Mental Health Practice Act, the Colorado Medical Board's Guidelines for the Appropriate Use of Telehealth Technologies, and DORA's published guidance on psychotherapy through electronic means.

How Telehealth Works

Telehealth means the delivery of mental health services through HIPAA-compliant telecommunications systems, including live two-way audio and video. By signing this document, you confirm that you understand and agree to the following:

• All sessions are conducted via live, real-time, two-way audio/video — email, chat, or text alone do not constitute a therapy session under Colorado standards
• You must be physically located in the State of Colorado at the time of each session
• Your clinician is licensed in Colorado and services are governed by Colorado law
• You will be in a private, secure location during sessions
• You will use a secure, stable internet connection with a working camera and microphone
• You understand you may be asked to confirm your physical location at the start of each session

Risks and Benefits of Telehealth

Telehealth has many benefits, including increased access to care and convenience. There are also potential limitations and risks, including:

• Technology failures (internet outage, device failure) that may interrupt a session
• Reduced ability for your clinician to observe non-verbal cues compared to in-person care
• Potential (though unlikely with HIPAA-compliant platforms) for unauthorized access to transmissions
• Telehealth may not be appropriate for every client or every clinical situation

Your clinician retains clinical discretion to determine whether telehealth is appropriate for your specific needs. If in-person services are clinically indicated, you will be referred to an appropriate provider.

Your Right to Choose

You have the right to withdraw consent to telehealth services at any time. Withdrawal will not affect your right to seek other referrals or care. If you prefer in-person services, I will assist you in locating an appropriate in-person provider.

Emergency Protocol — Colorado-Specific

I am not a crisis counselor and am not available on call for crisis. If you are in a mental health emergency, please use the following resources:

• 988 Suicide & Crisis Lifeline — Call or text 988, or webchat at https://988lifeline.org/ (24/7, available in Colorado)
• Colorado Crisis Services — 1-844-493-8255 (24/7) | Walk-in crisis centers statewide
• Text HOME to 741741 — Crisis Text Line
• 911 — Immediate emergencies
• Nearest hospital Emergency Room

Colorado Crisis Services walk-in locations: coloradocrisisservices.org/locations

In accordance with Colorado law, your clinician maintains a current list of crisis resources, hospitals, and urgent care facilities near your location. At the start of services, you should provide your clinician with your current address so local resources can be identified for your area.

If your needs exceed what telehealth can safely provide, your clinician will make a good-faith effort to coordinate with emergency services in your area and will provide you with referral resources.

CONFIDENTIALITY

Your participation in clinical services, the content of sessions, and any information maintained about you is protected by legal confidentiality under Colorado law, including C.R.S. § 12-43-218 and applicable federal law. Exceptions to confidentiality include:

• If you provide written consent to release information to another party
• In the case of your death or disability, disclosure to your personal representative
• If you waive confidentiality by bringing legal action against your clinician
• In response to a valid court order or subpoena
• If your clinician reasonably believes disclosure is necessary to avoid or minimize imminent danger to your health or safety, or the health or safety of any other person (C.R.S. § 12-43-218)
• If you make a threat of imminent physical harm — your clinician is required to report to law enforcement and to warn the person(s) threatened
• If a client is found to be imminently dangerous to themselves or others, or gravely disabled due to a mental disorder — your clinician is legally required to initiate a mental health evaluation
• To county coroners or medical examiners for investigation of deaths
• To coordinate referrals and care with other current or former providers you are receiving care from
• To coordinate payment with third-party payers for services rendered

Mandatory Reporting — Colorado Law

As a mandatory reporter under Colorado law, your clinician is required to report:

• Suspected child abuse or neglect — reported to the Colorado Child Abuse and Neglect Hotline (1-844-CO-4-Kids) within 24 hours of becoming aware in a professional capacity, per C.R.S. § 19-3-304 as amended by HB25-1188 (effective September 1, 2025)
• Abuse, neglect, or exploitation of an at-risk adult or person with a disability
• Any observed or reported circumstances placing a child at immediate risk

Note: Under 2025 updates to Colorado law, mandatory reporting applies only when the information is learned in a professional capacity. Reports cannot be made solely on the basis of a family's race, ethnicity, socioeconomic status, or disability.

WORKING WITH MINORS

Rocky Mountain Thrive works with clients ages 12 and older. Under Colorado law (C.R.S. § 27-65-103 and related statutes):

• Minors age 15 or older may independently consent to outpatient mental health treatment in certain circumstances — your clinician will confirm applicable law for your minor client's specific situation
• For clients under 18, it is generally required that a parent or legal guardian provide consent to treatment
• Under C.R.S. § 14-10-123.8, parents have the legal right to access mental health treatment information regarding their minor children, unless a court order restricts this access. Your clinician may provide a treatment summary that complies with Colorado law and HIPAA.

Additional requirements for minor clients:

• A copy of any parenting plan, custody order, or court order affecting the minor must be provided to your clinician before treatment begins, and any updates must be provided promptly
• Where there are two custodial parents or guardians, consent from both is generally required

I am not able to provide recommendations, evaluations, or opinions in any legal forum relating to separation, divorce, child custody, visitation, or parenting plans. If these services are needed, I can provide referrals to a qualified forensic evaluator.

INSURANCE PROVIDERS & FEES

Session Fees

The cost of sessions is provided in your separate Good Faith Estimate document. Please review that document carefully. I also accept major insurance plans as listed on our website at www.rockymountainthrive.com.

In-Network Insurance Billing

For clients using in-network insurance:

• An active credit card must be kept on file for co-pays, co-insurance, and/or session fees if insurance is declined
• You must provide a copy of the front and back of your insurance card
• You are solely responsible for confirming benefits and coverage with your insurance company
• If claims are denied, you will be notified, your card on file will be charged the full session fee, and any amount later recovered from insurance will be refunded
• You must notify your clinician at the start of any session if your insurance has changed

Out-of-Network & Private Pay

For out-of-network or private pay services, your insurance company may request the following to process claims:

• Type of service provided and CPT code
• Dates and times of service
• Your diagnosis
• Treatment plan or description of impairment
• Progress notes or summaries

If you do not wish for this information to be shared with your insurance company, please inform your clinician so we can discuss private pay alternatives.

Payment Policies

• Out-of-network sessions: Payment is due at the start of each session
• In-network sessions: Co-payment and co-insurance are charged after insurance payments are confirmed
• Past due balances: To protect the therapeutic relationship, clients may not carry unpaid balances. If a past due balance is not resolved before your next session, that session may be canceled and your time slot released. Referrals to low-cost services will be provided.

Cancellation Policy

• 24 hours advance notice is required to cancel an appointment without charge
• Late cancellations or no-shows will be charged the full session fee
• After two late cancellations or one no-show in any 6-month period, your regular time slot will not be held and care may be terminated
• We require at least one session every 30 days to maintain an active file. If your file is closed, new onboarding documentation will be required to restart services

Additional Services

Letters, forms, and other documentation completed on your behalf are billed at $200/hour, charged to the card on file. An estimated cost will be provided in advance.

If your clinician's participation is required in legal proceedings, the rate is $400/hour for all preparation, participation, travel, and waiting time.

Services Not Provided

Rocky Mountain Thrive provides professional counseling and psychotherapy, not evaluative services. We do not provide:

• Emotional Support Animal (ESA) recommendation letters
• Disability evaluations
• Evaluations for work leave
• Forensic evaluations or preparation for litigation

If you require forensic or evaluative services, we will provide appropriate referral resources.

FAMILY AND RELATIONSHIP COUNSELING

If you are participating in family or relationship counseling:

• Your clinician will adhere to all ethical and legal confidentiality requirements
• The entire treatment record will be available to all participants in the family or relationship counseling
• Your clinician cannot maintain secrets between members — if clinically appropriate disclosure cannot be arranged, the clinical relationship may need to be terminated with referrals provided
• All participants must consent to any authorized third-party disclosure
• Your clinician cannot ensure that other participants will maintain confidentiality about session content

GROUP COUNSELING

If you are participating in group counseling:

• Your clinician will adhere to all ethical and legal confidentiality requirements
• You are expected to maintain the confidentiality of information shared by other group members — however, your clinician cannot guarantee that other participants will do so
• Group therapy may be billable to insurance — please confirm with your insurance provider
• By enrolling in a group therapy series, you are committing to the full series
• Late cancellation/no-show fees apply to group sessions as described in your Good Faith Estimate

SUPERVISION & CONSULTATION

Your clinician may participate in regularly scheduled clinical supervision and peer consultation to provide the highest quality of care. In those contexts, the minimum necessary information about your care may be shared in a confidential manner.

NOTE-TAKING AND AI-ASSISTED DOCUMENTATION

As part of clinical practice, your clinician may use artificial intelligence-powered tools to assist with clinical documentation, enabling more accurate and complete session notes.

How AI tools are used:

• All AI tools used are HIPAA-compliant and covered by a signed Business Associate Agreement (BAA)
• AI tools produce only a rough first draft — your clinician personally reviews and finalizes all documentation
• AI is never used to deliver clinical services or make decisions about your care

Please let your clinician know if you have any questions or concerns about this process.

ELECTRONIC COMMUNICATIONS AND SOCIAL MEDIA POLICY

Email and Text Communication

Rocky Mountain Thrive provides a text and phone line for general communications such as scheduling, running late, and administrative questions. Clinical matters should not be communicated via text or email.

• Appointment reminders are managed through our secure EHR system
• Your clinician cannot guarantee the security or confidentiality of information sent via unencrypted email or text
• You consent to being contacted via text if you have not appeared for or appear to be running late for a scheduled appointment
• Response time: generally within 48 business hours, Monday–Friday. If you are in crisis, do not use email or text — use 988 or 911.
• We do not share your mobile number with third parties. Our privacy policy is located at www.rockymountainthrive.com/privacy
• Message frequency varies. Standard message and data rates may apply. Reply STOP to opt out, HELP for help.

Social Media

• Your clinician will not follow clients on social media to protect confidentiality and prevent dual relationships
• Do not use any professional or personal social media as a mode of direct clinical communication
• A professional social media presence may be maintained for general public information only
• Connecting to a professional social media presence may disclose your therapeutic relationship

RECORDS RETENTION

Clinical records are maintained in compliance with Colorado law and professional standards. Under Colorado regulations, mental health records must be retained for a minimum of 7 years following the last service date, or for 7 years after a minor client reaches the age of 18, whichever is longer.

After the applicable retention period, records are destroyed in a secure and confidential manner. Records are kept in a HIPAA-compliant electronic health record system.

TERMINATION OF SERVICES

If we have not had contact in 30 days without prior arrangements, your active file may be closed. A new episode of care can be initiated upon scheduling.

You have the right to terminate therapy at any time. If you choose to end therapy, it is recommended that you schedule a final session to discuss your progress and any ongoing needs.

Your clinician may also initiate termination of services if: your needs exceed the scope of services provided, you are not making progress, you are not engaging in the therapeutic process, or for other clinical or ethical reasons. In such cases, referral resources will always be provided.

STATE OF COLORADO REQUIRED DISCLOSURES

Your Rights as a Client

As a client in Colorado, you have the right to:

• Refuse treatment
• Choose a practitioner and treatment modality that best suits your needs
• Receive a copy of this disclosure statement
• Ask questions about your treatment, your clinician's credentials, and your rights at any time
• Request referrals if your needs are beyond the scope of services offered

Professional Regulation in Colorado

Licensed and registered mental health practitioners in Colorado are regulated by the Colorado Division of Professions and Occupations (DORA). Credentialing with DORA does not constitute recognition of any specific practice standard, nor does it imply the effectiveness of any particular treatment.

Filing Complaints in Colorado

If you have concerns about unprofessional conduct, you may file a complaint with:

Colorado Division of Professions and Occupations — Mental Health Licensing Section
1560 Broadway, Suite 1350, Denver, CO 80202
Phone: (303) 894-7800
Email: dora_dpo_licensing@state.co.us
Website: dpo.colorado.gov

Clinician Credential Disclosure (Required by Colorado SB24-082)

In accordance with Colorado law effective January 1, 2025, the following information is provided in writing at or before the time of informed consent:

• Clinician Name: [Full Name]
• Professional Credential: [e.g., Licensed Professional Counselor (LPC) / Licensed Clinical Social Worker (LCSW) / Licensed Marriage and Family Therapist (LMFT)]
• Colorado License Number: [License Number]
• Issuing Board: [e.g., Colorado State Board of Licensed Professional Counselor Examiners]
• Supervision Status: [Independent practice / Supervised by: Name, Credential, License #]

CONSENT FOR TREATMENT

By signing this document, you confirm that you:

• Have received, read, and fully understand the disclosures, terms, and conditions above
• Have received a copy of the Rocky Mountain Thrive Notice of Privacy Practices (HIPAA)
• Have read and understand your rights under HIPAA
• Have been given the opportunity to ask questions and have had them answered to your satisfaction
• Consent to participate in counseling and psychotherapy services provided by the clinician named in this document
• Understand that telehealth services are governed by Colorado law and that you must be physically located in Colorado during each session
• Understand the limitations of telehealth and the availability of in-person alternatives
• Acknowledge that you have received the Good Faith Estimate for the cost of services

Your signature constitutes informed, voluntary consent to the terms of this agreement.

IF CLIENT IS A MINOR — Guardian Consent

I am the legal parent or guardian of the minor client named above and consent to their participation in mental health services at Rocky Mountain Thrive.

Clinician Acknowledgment

By signing below, I confirm that I have reviewed this document with the client, answered their questions, and provided them with a copy.