[ninja_form id='2']
Who is your clinician? -- Select Clinician --Jackie JohnsonDustin JohnsonChelsea Cashman Informed Consent and Disclosure Statement Colorado Law requires this form prior to engaging in therapy. Please read it carefully and raise any questions that you may have. Peak Clarity Counseling Center 2625 Redwing Rd. Suite 110 Fort Collins, CO 80526 970-480-0707 Dustin Johnson, LPC Professional Counselor Lic.#11971 Georgia Tech 1998, GSU 2010 My Focus is to help clients understand the cause of their suffering and help them establish a happy, healthy, and functional life. If there does not appear to be a good match between my skills and the client’s concerns, I will make appropriate referrals. You can ask questions at any time about my counseling techniques and your counseling experience. Counseling does not necessarily cause one to feel better immediately; progress can take time and is highly related to client’s effort between sessions. Everything discussed in our sessions is considered legally confidential with a few exceptions: 1. I am legally required to report suspected child abuse or elder abuse to the proper authorities. 2. I also may take some action without your consent if I believe you to be in danger of doing serious harm to yourself or another or if you are gravely unable to care for yourself. 3. If ordered by the Court I will provide reports as to your counseling. Appointments: Most clients are on a regular appointment schedule. The quickest way to make an appointment is by email, though you may also phone. Crisis: If you are a current client and in crisis, you may call me and I will make every effort to schedule you as soon as possible. If you are in immediate crisis contact the Suicide Prevention Helpline (800-273-8255) or go to Poudre Valley Hospital emergency room (1034 Lemay St, Ft Collins). Fees and Payment: My self-pay rate $125.00 per 55-minute session, except for the first session, which is $150.00. I offer a $25.00 discount for cash payments. + $20.00 for each additional 10 minutes. Payment for services is due to me at the beginning of each session. I take cash, checks (made out to Peak Clarity), and credit cards. If you pay in cash, please bring the exact amount. Cancellations must be made 24 hours in advance. If you fail to do so, a $35.00 fee will be charged to you. Insurance: If I am on your insurance panel, I will bill your insurance at your request. You will be responsible for any co-pay or deductible amounts not covered by your plan. Records include copies of signed forms, dates of sessions, treatment plan, brief progress notes, copies of correspondence, and verification of any other contacts made. Your records are safely and confidentially stored electronically. Your records will be treated in a manner consistent with HIPPA guidelines. You have been provided a copy of the guidelines. Any request for release of this information will need your approval and signature on a written form. Social Media and Email: I do not use social media, such as Facebook or Twitter, to stay in contact with active clients. Email is inherently not a secure form of communication. I do respond to emails, but I cannot guarantee the confidentiality of email communications. Ending counseling will usually be agreed upon mutually. You are free to end counseling at any time. I may end your counseling, even though you wish to continue, if I believe you need services which are outside my competency, if there has been prolonged failure to make progress in our work together, or I believe you pose a threat to my safety. Should any of these occur, I will explain my decision to you and will recommend other appropriate resources. Problems that you have with our work together can always be discussed between us. If you have a complaint that you wish to take further, you may contact the Colorado Department of Regulatory Agencies, Mental Health Section. Phone number is 303-894-7800. Address is 1560 Broadway #1350, Denver, CO. 80202. In addition, Colorado law requires that I inform you that in any professional psychotherapeutic relationship sexual intimacy is never appropriate and should be reported to the Colorado Department of Regulatory Agencies Office Policies: Please review and initial each: ____ I understand that the recommended frequency of therapy for most issues is weekly for the first few weeks. I agree to make therapy a priority in my life, both during and between sessions. ____ Standard therapy sessions are 55 minutes in length. A reminder chime will sound at 50 minutes. I agree to bring up important issues early in the session so that they may be addressed adequately. ____ For cancellations of less than 24 hours in advance, I agree to pay a fee of $35, and that this may be charged to my credit card on file. ____ I understand that if I late cancel more than 2 sessions in any 3-month period, future appointments may be cancelled and I may have to wait until there are new openings in the practice before rescheduling. ____ I accept that email is inherently insecure. If I choose to correspond with my therapist by email, I accept the risks that come with it. You have been provided with a copy of this document. Signing below indicates you have been informed of Dustin Johnson’s degrees and licensing status. Additionally, you have read the preceding information and understand you rights as a client. You have been provided information about crisis resources. Your Name (required) Your Email (required) Subject Your Message Δ
Who is your clinician? -- Select Clinician --Jackie JohnsonDustin JohnsonChelsea Cashman
Colorado Law requires this form prior to engaging in therapy. Please read it carefully and raise any questions that you may have.
Peak Clarity Counseling Center 2625 Redwing Rd. Suite 110 Fort Collins, CO 80526 970-480-0707 Dustin Johnson, LPC Professional Counselor Lic.#11971 Georgia Tech 1998, GSU 2010
My Focus is to help clients understand the cause of their suffering and help them establish a happy, healthy, and functional life. If there does not appear to be a good match between my skills and the client’s concerns, I will make appropriate referrals. You can ask questions at any time about my counseling techniques and your counseling experience. Counseling does not necessarily cause one to feel better immediately; progress can take time and is highly related to client’s effort between sessions.
Everything discussed in our sessions is considered legally confidential with a few exceptions: 1. I am legally required to report suspected child abuse or elder abuse to the proper authorities. 2. I also may take some action without your consent if I believe you to be in danger of doing serious harm to yourself or another or if you are gravely unable to care for yourself. 3. If ordered by the Court I will provide reports as to your counseling.
Appointments: Most clients are on a regular appointment schedule. The quickest way to make an appointment is by email, though you may also phone.
Crisis: If you are a current client and in crisis, you may call me and I will make every effort to schedule you as soon as possible. If you are in immediate crisis contact the Suicide Prevention Helpline (800-273-8255) or go to Poudre Valley Hospital emergency room (1034 Lemay St, Ft Collins).
Fees and Payment: My self-pay rate $125.00 per 55-minute session, except for the first session, which is $150.00. I offer a $25.00 discount for cash payments. + $20.00 for each additional 10 minutes. Payment for services is due to me at the beginning of each session. I take cash, checks (made out to Peak Clarity), and credit cards. If you pay in cash, please bring the exact amount. Cancellations must be made 24 hours in advance. If you fail to do so, a $35.00 fee will be charged to you.
Insurance: If I am on your insurance panel, I will bill your insurance at your request. You will be responsible for any co-pay or deductible amounts not covered by your plan.
Records include copies of signed forms, dates of sessions, treatment plan, brief progress notes, copies of correspondence, and verification of any other contacts made. Your records are safely and confidentially stored electronically. Your records will be treated in a manner consistent with HIPPA guidelines. You have been provided a copy of the guidelines. Any request for release of this information will need your approval and signature on a written form.
Social Media and Email: I do not use social media, such as Facebook or Twitter, to stay in contact with active clients. Email is inherently not a secure form of communication. I do respond to emails, but I cannot guarantee the confidentiality of email communications.
Ending counseling will usually be agreed upon mutually. You are free to end counseling at any time. I may end your counseling, even though you wish to continue, if I believe you need services which are outside my competency, if there has been prolonged failure to make progress in our work together, or I believe you pose a threat to my safety. Should any of these occur, I will explain my decision to you and will recommend other appropriate resources.
Problems that you have with our work together can always be discussed between us. If you have a complaint that you wish to take further, you may contact the Colorado Department of Regulatory Agencies, Mental Health Section. Phone number is 303-894-7800. Address is 1560 Broadway #1350, Denver, CO. 80202. In addition, Colorado law requires that I inform you that in any professional psychotherapeutic relationship sexual intimacy is never appropriate and should be reported to the Colorado Department of Regulatory Agencies
Office Policies: Please review and initial each:
____ I understand that the recommended frequency of therapy for most issues is weekly for the first few weeks. I agree to make therapy a priority in my life, both during and between sessions.
____ Standard therapy sessions are 55 minutes in length. A reminder chime will sound at 50 minutes. I agree to bring up important issues early in the session so that they may be addressed adequately.
____ For cancellations of less than 24 hours in advance, I agree to pay a fee of $35, and that this may be charged to my credit card on file.
____ I understand that if I late cancel more than 2 sessions in any 3-month period, future appointments may be cancelled and I may have to wait until there are new openings in the practice before rescheduling.
____ I accept that email is inherently insecure. If I choose to correspond with my therapist by email, I accept the risks that come with it.
You have been provided with a copy of this document. Signing below indicates you have been informed of Dustin Johnson’s degrees and licensing status. Additionally, you have read the preceding information and understand you rights as a client. You have been provided information about crisis resources.
Your Name (required)
Your Email (required)
Subject
Your Message
Δ
