Elizabeth (Liz) Hartman, MA, LPC
MANDATORY DISCLOSURE STATEMENT, INFORMED CONSENT, AND CANCELLATION POLICY
This disclosure statement is in compliance with the State of Colorado, Department of Regulatory Agencies, Colorado
Education and Experience
Elizabeth (Liz) Hartman is a licensed psychotherapist in the state of Colorado, License #3172. Liz earned her bachelor’s degree from the University of Northern Colorado and a master’s degree from the University of Colorado at Denver.
The fee for a 50-minute therapy session is $150.00 in the office and $125.00 for a video session.
Clients will be billed for full sessions for missed appointments canceled with less than 24 hours notice.
Checks should be made payable to Elizabeth Hartman, LPC. Returned check fee is $20. In the event an account is referred to collections, the client agrees to pay reasonable attorney’s fees and court costs if any.
A detailed statement of service will be provided upon request. Insurance may provide coverage for a portion or all of your session fee. You will be responsible for billing your insurance. Elizabeth Hartman will assist by providing needed documentation for your insurance. Whether or not you are using insurance, it remains the client’s responsibility to pay for sessions at the date of service, unless other arrangements have been agreed upon ahead of time.
The practice of psychotherapy is regulated by the state of Colorado Department of Regulatory Agencies.
The agency within the department that has responsibility specifically for licensed psychotherapists is the
CO Dept. of Regulatory Agencies
1560 Broadway, Suite # 1340, Denver, CO 80202,
I understand that if I am outside the state of Colorado, Liz will be referred to as a life coach under the title of Elizabeth M. Hartman, MA.
I, the understated client, understand that I may seek a second opinion from another therapist or may terminate therapy at any time and that, at termination, a closure session is generally recommended when possible.
I understand that any information I provide during the therapy practice, is legally confidential; the therapist cannot be forced to disclose the information without my consent.
The following are exceptions to client confidentiality:
1. I am required to report any threat of imminent physical harm by a client to law enforcement and
to the person(s) threatened.
2. I am required to initiate a mental health evaluation of a client who is imminently dangerous to
self or others, or who is gravely disabled as a result of a mental disorder.
3. If there is reason to believe that child abuse or neglect has occurred, I am required to report it
to Social Services for their investigation. I am required to report abuse that happened in the past when the client is 18 years of age or older if the abuser is currently in a position of trust with children.
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. Often it is required that I release information in legal suits.
(970) 485-1130 firstname.lastname@example.org
Elizabeth (Liz) Hartman, MA, LPC
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 this information. If you request treatment information I may provide you with a treatment summary in compliance with Colorado Law and HIPAA standards. For reports in addition to insurance statements, I charge at my hourly rate.
Our sessions are strictly confidential. I do meet regularly with other psychotherapists to consult about treatment issues. Clients’ names are not disclosed. These experts also are bound to protect clients’ confidentiality.
In a professional relationship such as ours, sexual intimacy is never appropriate. If sexual intimacy does occur between a therapist and a client, it should be reported to the Department of Regulatory Agencies.
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 state of Colorado requires that I list the requirements for different types of mental health professionals. Licensed Professional Counselors, Licensed Clinical Social Workers and Licensed Marriage and Family Therapists 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 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 certified Addiction Counselor I (CAC I) must be a high school graduate and complete required training hours and 1000 hours of supervised experience. A CAC II must complete additional required training hours and 2000 hours of supervised experience. A CAC III must have a bachelor’s degree in behavioral health and complete additional required training hours and 2000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical master’s degree and meet the CAC III requirements. A registered psychotherapist is registered with the State Board of Registered Psychotherapists. No degree, training or experience is required of them.
I have read the preceding information, and the credentials provided, and understand my rights as a client. Signing this form indicates my informed consent to receive treatment.