DISCLOSURE & CONSENT STATEMENT
Denice C. MacKenzie RN, CS
T.L.C. Counseling, Inc.
Denice C. MacKenzie T.L.C. Counseling, Inc.
7050 W. 120th Avenue Denice MacKenzie RN, CS
Broomfield, CO 80021 www.TLCCounseling.com
(303) 929-4205 Denice@TLCcounseling.com
1977 BA in Psychology; University of Colorado
1985 BSN in Nursing; University of Colorado Health Sciences Center, License # 81137
1991 MS Psychiatric Nursing; Rutgers University; Newark, NJ
1993 Licensed Adult Psychiatric Clinical Nurse Specialist; A.N.C.C., License # 0227980-01
2001 Trained in Eye Movement Desensitization and Reprocessing Therapy (E.M.D.R), Levels I and II
2008 Trained in Christian Mind Body Therapy, Splankna Institute, Levels I and II
The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of licensed psychologists, clinical social workers, counselors, marriage and family therapists, school psychologists, clinical nurse specialists and unlicensed individuals who practice psychotherapy. The agency within the Department that has the responsibility for Nurses is the State Board of Nursing; 1560 Broadway, Suite 880; Denver, CO 80202; 303-894-2430. I do not prescribe medications.
Client Rights and Important Information
1) You are entitled to receive, upon request, any information from me about my methods of therapy, the techniques I use, the estimated duration of your therapy (if determinable), and my fee structure.
2) You can seek a second opinion from another mental health professional and/or terminate at any time.
3) In a professional relationship, I am required by law to state, that sexual intimacy between a therapist and a client is never appropriate. This should always be reported to the State Grievance board.
4) Confidentiality: 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 written consent. There are several exceptions to confidentiality which include but are not limited to (a) any suspected child abuse, neglect or elder abuse must be reported to law enforcement (b) any threat of imminent physical harm by a client must be reported to law enforcement and to the person(s) threatened; (c) 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 (d) I am required to report any suspected threat to local or national security under the terrorism act, to federal officials (e) I am required to disclose necessary client information to insurance companies for reimbursement (f) I may discuss client information, not using names, upon receiving supervision with other qualified therapists.
I understand the above exceptions to confidentiality. (initial) ____________
5) Payment is due upon visit. There will be a $75.00-125.00 fee for any missed session,, except in the case of some emergencies that are not preceded by 24 hour advanced notice via phone message, text, or direct contact. If a session is moved to Zoom due to Covid or weather, that is not considered reason for cancellation and fees still apply. Please do not contact me by email when you are cancelling a session, only by phone call or text. I do not check emails daily. You may still be charged a late fee if you cancel via email only and I do not receive it. (initial)_________
6) After Hours and Emergent Care: The phone number for reaching me in an urgent situation is 303-929-4205. You are free to do so during the week Tuesday through Thursday between 9 am and 7 pm. Out side those hours if you have a psychiatric emergency, you can call Centennial Peaks Hospital at any time at 303-673-9990 or present yourself to the nearest emergency room. Initial ______
7) I am not contracted with any insurance companies. I understand that payment is strictly full fee at my hourly rates and due upon date of service (see website and financial consent form). (initial)_________.
(8) As your therapist, if I’m ever placed in a situation where I am to resist disclosure of your record in a legal situation on your behalf in order to protect your confidentiality, and have to incur fees, you will be responsible for all fees incurred. You are also responsible for any legal fees incurred from testifying in court on your behalf, should efforts to resist fail. I also understand that needed phone consultations with others involved in my treatment, and with myself, will be charged at full fee (Initial) ___________.
9) If you abruptly terminate therapy without going through the termination process with the therapist, I will attempt to contact you. If I do not hear back from you within two weeks, I will consider you as discharged from therapy, and will attempt to send you an email in regards to that. (Initial)________.
10) I acknowledge that, in the event that the undersigned therapist becomes incapacitated or dies, it will become necessary for another therapist to take possession of my file and records. By signing this information and consent form, I give my consent to allow another licensed mental health professional, selected by the undersigned therapist, to take possession of my file and records and provide me with copies upon request, or to deliver them to a therapist of my choice. If you are a current patient, you will be notified
Theoretical Orientation
I use a variety of techniques in my counseling and strive to adhere to best practice guidelines and well-researched modalities. These may include family systems, cognitive, developmental, attachment and trauma focused processing techniques. I also use integrative approaches that address the body, mind and spirit as a connected unit. I work from the belief that symptoms exist within an individual for some logical function, rather than just as “pathology”. These symptoms manifest consciously and subconsciously and are often stored in the body and subconscious belief “systems” which are formed during times that are traumatic to the individual. Mind/body/spirit interventions are employed to clear previous trauma and assist the client to build new belief systems, thus relieving the current symptoms. I work to help clients have integrity within their value systems, since this promotes better mental health. As a result, spiritual questions may be a part of the original assessment. Light touch is involved in some treatments if they are chosen. The type of therapy to be used for your treatment will be decided and discussed together with your full consent. At any time you are free to question or refuse any therapeutic modality or practice, as you see fit.___________(Initial)
Consent to Treatment
By signing this consent form, you are giving your consent to the undersigned therapist to share confidential information with all persons in the situations outlined above. You are also releasing and holding harmless the undersigned therapist from any departure from your right of confidentiality that may result from the actions listed above, initiated by other persons or agencies. .
I have read the preceding information and understand my rights as a client. I do hereby accept full responsibility for any and all actions taken by myself, my child or my teenager concerning any therapeutic assignments, mind/body work or spiritual work with Denice MacKenzie and TLC Counseling. I understand that I have full choice as to what therapeutic modality is used during my sessions. I understand that I am not receiving medical diagnosis, medical treatment or prescriptions for medication, but psychotherapeutic interventions only. I understand it is my responsibility to seek appropriate medical or psychiatric care while receiving therapy at TLC Counseling. I understand that Denice will do her best to assess and treat me, but results are not guaranteed and that I can refuse any therapy that is offered. I hereby release TLC Counseling and Denice C. MacKenzie, RN, CS, from any liability resulting in any damage or loss incurred during our association.
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Client Signature Date
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Therapist/ Witness Signature Date