The Interpersonal Healing Clinic, LLC (The IHC)

Owner:  Lisa M. Templeton, Ph.D., Licensed Clinical Psychologist

Please Read Carefully

You should not consider your communication with us legally protected or confidential until you are told by us that your communication is protected or until you are told that you are a client or patient. 

Please let me know if you have any questions before you sign or agree to the terms of this document.  Please complete this consent form and the attached history and background.  Your honesty will allow your provider to begin to understand your unique and personal needs.  This information, like all information that you a share with your provider, is private and confidential. State and professional psychologists’ standards suggest that you be informed of all possible contingencies that might arise in the course of short-and long-term therapy. Please check to be sure you have read, understood, and discussed all questions with your provider. Generally, the cost for an initial evaluation session is $120. Therapy appointments thereafter cost $100 (per 50-minute session), unless you have made other arrangements with the provider.  If you are paying through your insurance or EAP, please be sure to be aware of your copay schedule.  Payment is expected at the time of service.

SERVICES AGREEMENT  For Dr. Lisa M. Templeton, Ph.D., Dr. John Steele, Ph.D., Amy Grauberger, M.A., Wendy Pollock, M.A., LPC, Stephanie Helsel, M.A., LPC, and Christian Ogden, M.A., LPC, Marsha Kravetz, M.A., LMFT, LPC

This document (the Agreement) contains important information about professional services provided and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA).

Treatment Information

  Services Provided. Services provided include therapeutic assessments, counseling, psychotherapy, psychological evaluations, assessment based interventions, crisis intervention, and client education. No service will be provided without your consent. 

Treatment is Optional and Not Required. Counseling, psychotherapy and crisis intervention services are not required, unless mandated by state or federal courts.  You are free to limit or end treatment at any time.  I would prefer that you speak with your provider and he/she can give you appropriate referrals, but you are under no obligation to do so.

Consultation. From time to time your provider may find it necessary or helpful to consult with other professionals about their work with you. The Interpersonal Healing Clinic (The IHC) believe in using a team approach when necessary, but will not provide your name to people we consult with, unless you have signed a release of information form.  Regardless, consulted parties will be bound by the same laws and ethical standards as the IHC in terms of confidentiality.

Service Orientation and Approach. The approach of the Interpersonal Healing Clinic (The IHC) is to  primarily focus on problem solving with cognitive-behavioral and interpersonal psychotherapy and counseling to support specific problems. Therapy and counseling services are intensive and can result in significant stress as you will be asked to change your behavior. Your provider will provide information, recommendations and a therapeutic environment intended to give my clients meaningful choices and I view the healing process as a collaborative effort. 

Health Insurance. Some patients may choose to seek reimbursement from their health insurance for services. Your provider will bill your insurance company if he/she is paneled under that health insurance. Please check with your health insurance prior to our first visit to ascertain your co-pay and assure you have an authorization number. If you do not have an authorization prior to our first session, you may be liable for out of pocket payment for that session.  Your provider may ask that any third party who pays for your services (such as a parent or friend) to obtain a release from you and explain the purpose and use of such information.

Methods. Services provided include individual, family, couples/marital, group, crisis and education. The focus of services are primarily educational and interpersonal with some psychodynamic interpretation directed to providing insight, depending on each individual client.  Cognitive, behavioral, interpersonal, existential and humanistic methods are primarily used to guide services.

Unique Approaches. Family and individual services with unique approaches are provided when appropriate on weekends or after hours. The practice of the Interpersonal Healing Clinic (IHC) is primarily educational and may be active with patients in a natural environment. Therapy may include psychospiritual and creative tools for healing depending on the willingness of each client.  For instance, music may be used directly (i.e., drums, listening to music) or indirectly (looking at music lyrics to favorite songs).  In some cases, it might be more effective to leave the office in order to face a fear of crowds.  Your provider also may take patients or groups of patients on walks and enjoy wilderness as a means for healing.  These activities would only be offered as a means to support consultation, treatment and evaluation goals. All treatment and supportive services are optional. Patients are not required to participate in any creative or spiritual approaches to treatment.

Time Parameters. Individual mental health services are 50 to 80 minute appointments one or two times a week, or can be every other week depending on the severity of the problem.  Family and group therapy are usually 1-11/2 hour appointments.  The work is designed to be short term (roughly 10-12 sessions), although some individual, family, or couples sessions and consultation services may be long term (up to one year or more). Crisis intervention services may require 1 to 3 months to resolve a crisis. Routine services can resolve most problems in two to six months and will usually average 2 months. Your provider will make every reasonable effort to be available for existing patients who require crisis services. Your provider may not be available due to illness or prior personal or professional commitments, but will make every attempt to notify my patients in advance if he/she will not be available.

Cancellations. The IHC requests 24 hours notice of any cancellation and will attempt to offer the same courtesy to you. Please call if unsure about canceling in inclement weather.  If you do not cancel with 24 hours notice, you will be charged the full fee for your appointment.  In order to assist patients in need, the IHC provides services to established and new patients during evening, weekends and early mornings. Failure to cancel an appointment may result in others not receiving the help they need and want. Your appointment times may be given to another patient if you fail to come to an appointment; therefore, the more notice of a cancellation, the better. 

Electronic Transmissions. Your provider may rely on e-mail or fax to keep in touch with you. The IHC believes private (not an employer's) e-mail or fax system is at least as secure as regular mail or the telephone. However, it is harder to tell if an e-mail has been opened or if an incorrect fax number is dialed.  Be cautious, in some cases an employer can monitor, keep copies and open your e-mail. Patients and clients may complete and submit their history and biographical information on-line or by fax. This submission method is at least as secure as mail.  All electronic records are purged from servers and computers. Hard copies are placed in patient files. As an alternative, you may print any intake forms available on-line and complete it using a pen and mail it, or bring it to your first appointment. You are not required to use e-mail or complete historical information on-line.

Risk of Life Changes. Therapy, counseling, crisis intervention, consultation and education services may have a profound impact. The work can be very intensive and as a result, stressful. Your provider will always give you the option to proceed slowly or at a more rapid pace. In most cases, there is improvement without unexpected problems. However, it is possible that there may be no change, problems or a disruptive change. For example, couples in conflict may decide to divorce. Children may become resistant to changes that you are making in your approach to parenting. Unexpected changes or results sometimes occur and cannot be predicted.

Consent of Minors. The IHC does not offer or provide services to minors without the permission of both parents, court or the legal guardian.  It is the policy of the IHC to work with children only when the parents are involved.  Minors who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records.  Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, for children between 14 and 18, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, the IHC will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. The IHC will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless the child is perceived to be in danger or is a danger to someone else, in which case, the provider will notify the parents of his/her concern. Before giving parents any information, the provider will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have.

Legal Issues. The IHC will not provide legal advice or forensic services as part of treatment. Your provider may bring up issues for you consider, but  recommend you seek legal opinions. Without mutual agreement, and a contract for services, your provider generally will not provide assessments or recommendations in support of legal actions such as child custody, competency evaluations, law suites or criminal charges.  Please notify your provider immediately if you are involved or may become involved in a legal or criminal matter. 

Contacting Your Provider. The providers for IHC will return your call within 24 hours.  If you are unable to reach a provider and feel that you can’t wait for us to return your call, contact your family physician or the nearest emergency room and ask for assistance regarding a mental health emergency. If your provider is unavailable for an extended time, the provider will provide current clients with the name of a colleague to contact, if necessary.

Explanation of Levels of Licensing.  A Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a masters 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 masters 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 2,000 hours of supervised experience. A CAC III must have a bachelors degree in behavioral health, and complete additional required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical masters degree and meet the CAC III requirements. A Registered Psychotherapist is registered with the State Board of Registered Psychotherapists, is not licensed or certified, and no degree, training or experience is required.

 

 

Fees and Payment Policy

The fee for service generally covers a 50 minute session and will be agreed upon in the first treatment session. The client will pay at the beginning of each session. As mentioned above, the cost is $120 for the initial evaluation and $100 for every session thereafter.  Cost of living increases may occur on an annual basis. Telephone calls may be charged at the same rate as personal consultation plus any telephone company charges. Interest at 12% per annum will be charged on all accounts over 60 days due.

The fees are established to provide services and to financially support marketing and education for the community.  Services are to be paid by cash or personal check.  The Person "Responsible for Payment" will be financially responsible for payment of such services. The Person Responsible for Payment is financially responsible for paying funds prior to or at the time services are provided.

As a service to you, upon your request, your provider will provide you with a billing statement and/or receipt that you can provide to your insurance companies and other third-party payers, but the IHC cannot guarantee such benefits or the amounts covered.  If you fail to pay your bill, the IHC will be forced to contact a collection agency to incur the amount due.

Please note that if you become involved in legal proceedings that require your provider's participation, you will be expected to pay for all of our professional time, including preparation and transportation costs, even if your provider is called to testify by another party. Because of the difficulty of legal involvement, the IHC and its providers charge $300 per hour for preparation, travel and attendance at any legal proceeding.

Payment methods include check made out to The IHC or cash.

Confidentiality

Confidentiality is a legal protection and assurance of your right to privacy to the fullest extent allowable by Federal and Colorado State statutes. Psychotherapy, counseling, assessment and associated services that are related to diagnosis, evaluation and treatment services provided by myself are confidential and protected in accordance with state law pertaining to my license as a practicing psychologist. This means that the patient has legal rights and the psychologist must take effective steps to keep the client’s records and treatment relationship private. Confidentiality does not apply if you are not our client or patient.  Confidentiality does not apply until you are told that you are a client or patient.

Limits of Confidentiality. You should be aware that your provider will likely practice with other mental health professionals in some cases and also share an office with another psychologist who is not affiliated with my practice. There may be individuals assisting the IHC with billing and procedural/scheduling issues.  In most cases, the IHC may need to share some of your protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member.

State law and professional ethics require therapists to maintain confidentiality in all cases except for the following situations:

1. If there is suspected child abuse, elder abuse, or dependent adult abuse.  Each provider is a mandated reporter, which means that they are under obligation to report any suspected abuse.  Once such a report is filed, the provider may be required to provide additional information.

2. In a situation in which serious threat to a reasonably well-identified victim is communicated to the therapist, the provider required to take action.  These actions may include notifying the potential victim, contacting the police, and/or seeking hospitalization for the patient.

3. When threat to injure or kill oneself is communicated to the therapist.  If the provider believes that a patient presents a clear and substantial risk of imminent, serious harm to him/her self, he/she may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection.

4. If you are required to sign a release of confidential information by your medical insurance.

5. Clients being seen in couple, family, and group work are obligated legally to respect the confidentiality of others. The therapist will exercise discretion (but cannot promise absolute confidentiality) when disclosing private information to other participants in your treatment process. Secrets cannot be kept by the therapist from others involved in your treatment.

6. Your provider may at times speak with professional colleagues about our work without asking permission, but your identity will be disguised.

7. Clients under 18 do not have full confidentiality from their parents.

8. It is also important to be aware of other potential limits to confidentiality that include the following:

a) All records as well as notes on sessions and phone calls can be subject to court subpoena under certain extreme circumstances. Most records are stored in locked files but some are stored in secured electronic devices.

b) Cell phones, portable phones, faxes, and e-mails are used on some occasions.

c) All electronic communication compromises your confidentiality.

9.  Some legal issues may override your rights to confidentiality.

a) If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. The IHC cannot provide any information without your (or your personal or legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.

b) If a government agency is requesting the information for health oversight activities, we may be required to provide it for them.

c) If a patient files a complaint or lawsuit against me, we may disclose relevant information regarding that patient in order to defend myself.

d) If a patient files a worker’s compensation claim, he/she automatically authorizes us to release any information relevant to that claim.

e) Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.

Note:  In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant or certificate holder.

The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Section of the Division of Registrations. The Board of Psychologist Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.

Please also see the HIPPA Notice - Notice of Policies and Practices to Protect the Privacy of Your Health Information.

HIPAA Notice

Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

The IHC may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

"PHI" (Protected Health Information) refers to individually identifiable health information. PHI includes any identifiable health information received or created by this office or myself. "Health information" is information in any form that relates to any past, present, or future health of an individual. Treatment is when the IHC provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when your provider consults with another health care provider, such as your family physician or another psychologist. Payment is when we obtain reimbursement for your healthcare. Examples of payment are when the IHC disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. "Use" applies only to activities within our [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. "Disclosure" applies to activities outside of our [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

The IHC may use or disclose confidential information (including but not limited to PHI) for purposes of treatment, payment, and healthcare operations when your written informed consent is obtained. Your provider may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when your provider is asked for information for purposes outside of treatment, payment and health care operations, he/she will obtain an authorization from you before releasing this information. Your provider will also need to obtain an authorization before releasing your psychotherapy notes. "Psychotherapy notes" are notes we have made about our conversation during a private, group, joint, or family counseling session. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Patient's Rights and Psychologist's Duties

Patient’s Rights:

  Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, your provider is not required to agree to a restriction you request.

  Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, we will send your bills to another address.)

  Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Your provider may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, your provider will discuss with you the details of the request and denial process.  Your provider may ask that we review the PHI and/or psychotherapy notes together in order for you to have an understanding of what is written.

Psychologist’s Duties:

The IHC is required by law to maintain the privacy of PHI and to provide you with a notice of  legal duties and privacy practices with respect to PHI. The IHC reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, the IHC is required to abide by the terms currently in effect. If the IHC revises policies and procedures, the IHC will post these in the office and mail you a copy if reasonably possible when information is requested from your file.

IV. Questions and Complaints

If you have questions about this notice, disagree with a decision made about access to your records, or have other concerns about your privacy rights, you may speak to the owner of the IHC, Lisa Templeton, Ph.D. about your concerns and/or send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The IHC can provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. Your provider will not retaliate against you for exercising your right to file a complaint.

V. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on April 14, 2003. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice when information is requested.  

Credentials Information for Lisa M. Templeton, Ph.D.: CO Practicing Psychologist Lic. # 3071

Ph.D. (2003).  The California School of Professional Psychology, San Francisco, CA.  Clinical Psychology.

2003-current: Adjunct Professor at Colorado Christian University as well as at University of Detroit and Rochester College, MI. 

M.A. Clinical Psychology (1998).  University of Detroit., Detroit, MI

Member, American Psychological Association since 1997

Credentials information for Amy Grauberger, M.A., CO registered psychotherapist, LPC Candidate:

A registered psychotherapist is a psychotherapist 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 a registration from the state.

M.A. (2010).  Colorado Christian University, Loveland, CO.  Psychology.

Professional Summary:

·          Counseled adults, children, and families who had been victims of family violence using Cognitive Behavioral, Person-Centered, Existential, Contemplative and Play therapies.

·          Provided counseling to pre and adolescent youths addressing self-esteem and behavior problems.

·          Communicated with parents about their children’s progress and development in a productive and supportive manner.

Credentials information for Christian Ogden, MA, LPC: LPC-5011

MA, (2008) The Naropa Institute, Boulder, CO   Transpersonal Counseling Psychology 3.9 GPA

BA,(1994) The Naropa Institute, Boulder, CO  Double Major, Psychology and Early Childhood Education

·          Worked in a variety of mental health settings and is experienced with a variety of ages and populations, including substance abuse treatment.

·          Trained and experienced in a variety of therapeutic methods including cognitive-behavioral, psychodynamic, existential, solution-focused, person-centered, and mindfulness-based.

Credentials information for Wendy Pollock, M.A., LPC: LPC-5984

M.A. (2008). Colorado Christian University, Loveland, Colorado.  Counseling

B.S. (1992). Western Michigan University, Kalamazoo, Michigan. Bachelor of Science.

·          Currently the Clinical Director at Alternatives to Violence, Loveland, CO

·          Been in practice working extensively with trauma and domestic violence since 2008

Credentials information for Stephanie Helsel, M.A., LPC: LPC-897

M.A. (1989).  University of Colorado, Denver, Colorado, Counseling

B.S. (1971).  Otterbein College, Westerville, Ohio,  Education, English, Speech/Theatre.

1994-PRESENT – Practicing as a therapist

1990-1994 - Counselor, Training Specialist, Employee Assistance Programs, Inc., Boulder CO.

Credentials Information for Marsha Kravetz, MA, LPC, LMFT, LPC-5250

M.A. Education Psychology (1981), Montclair State University, New Jersey

Clinical Member, American Association of Marriage and Family Therapy – Jan - current

 

 

 

I have been given a brief overview of the Services Agreement by my therapist and was also given an opportunity to ask questions. An overview of my rights and responsibilities were provided to me verbally as well. A copy of the services agreement has been provided to me should I have any questions in the future.

 

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Signature of client
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Printed name of client
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Signature of Person Responsible for Payment
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Printed name of Person Responsible for Payment
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Statement of the Therapist

This document was discussed with the client and questions regarding fees, diagnosis, and treatment plan were reviewed. I have assessed the client’s mental capacity and found the client capable of giving an informed consent at this time.  

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Signature of Therapist                                                     Date