Luminance Counseling and wellness services, LLC

5650 Greenwood Plaza Blvd Suite 225-A Greenwood Village, CO 80111

720-432-8809

Misha D. Grodt, MA, LPC

Informed consent / Professional Disclosure Statement

My highest earned degree is a Master’s (MA) in Clinical Mental Health Counseling from Argosy University. Additionally, I hold a BA in Anthropology from the University of Washington. I am a Licensed Professional Counselor with the state of Colorado, License #11565.

  1. The Colorado Department of Regulatory Agencies (DORA) has the general responsibility of regulating the practice of licensed psychologists, licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists, certified school psychologists, and unlicensed individuals who practice psychotherapy. The agency within DORA that has responsibility specifically is the Mental Health Section, 1560 Broadway, Suite 1350, Denver, CO 80202, (303) 894-7800.As to the regulatory requirements applicable to mental health professionals: a Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor 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 master’s 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 1,000 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 bachelor’s 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 master’s 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.
  1. It is important that you know the following information:
  1. You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy (if I can determine it), and the established fee structure. Please ask if you would like to receive this information.
  1. You may seek a second opinion from another therapist, or terminate therapy, at any time.
  1. In a professional relationship such as ours, sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the board that licenses, registers, or certifies the licensee, registrant, or certificate holder. (Information listed above in bold lettering).
  1. Because of the nature of the doctor-patient relationship, I can have no personal social contact with you, nor can I have any dual relationships with you (including social media such as Facebook), barter with you (exchange your professional services for mine, etc), or accept gifts. If you do wish to connect on Facebook, my professional page can be found at:
  1. To protect your confidentiality as a client, if we should happen to see each other in public, I will not acknowledge you unless you acknowledge me first.
  1. I am the sole proprietor of my practice, and I am not affiliated with any other practice or group, including those within my office building. I make all effort to comply with current HIPAA privacy standards.
  1. CONFIDENTIALITY: Generally speaking, information provided by and to a client during therapy sessions is legally confidential. If the information is legally confidential the therapist cannot be forced to disclose the information without the client's consent. The content of our sessions will remain confidential unless: a written release of confidentiality is signed by you authorizing me to speak with a specific person or group, a disclosure is court ordered, or a disclosure is mandated by state law.

There are mandated exceptions to your right to confidentiality, some of which are listed in section 12-43-218.

There are four conditions in which disclosure of privileged conversations is mandated by law: 1). any suspicion of child or elder abuse, 2). the client makes a credible threat to the physical well-being of others, 3). the client is likely to take his or her own life, and 4). I am court ordered to give testimony about your treatment. I will do my best to resist any subpoenas issued based on doctor-patient confidentiality. Most often courts uphold doctor-patient confidentiality, especially in civil matters, and do not compel clinicians to testify.

Also, if the client initiates any type of legal action against the therapist, all the clients’ rights to confidentiality are waived. Exceptions to the general legal rules of confidentiality can be found in the Colorado Statutes (C.R.S. 12-43-218 and the HIPAA Notice of Privacy Rights, (HIPAA notice has been provided to you via email, and copies are available in my office and on my website), as well as other exceptions in Colorado and Federal law.). You should be aware that provisions concerning disclosure of confidential communications shall not apply to any delinquency or criminal proceedings, except as provided in section 13-90-107 of the C.R.S. I will identify any exceptions that come up during therapy.

I may occasionally find it necessary to consult other professionals about your treatment. During a professional consultation, I will not give any identifying information about you. The consultant will also be legally and ethically bound to keep all information confidential. By the standards of practice in psychotherapy, such a consultation is not a violation of your confidentiality. Moreover, by signing this informed consent, you agree that I can use details of your case and treatment in various writings of articles. No overt identifying information will be offered, and I will often change the actual circumstances of the case when writing.

By Colorado state law, HIPAA, and the standards of practice in the profession, I am required to keep appropriate records of all treatment and services rendered. The confidentiality of these records is closely safeguarded.

  1. PROFESSIONAL FEES: All fees are due and payable at the time that services are rendered. The fee for adult individual therapy sessions (60 minutes) is $120. The fee for 90 minute session or a session with loved ones is $170. You may pay by using cash, check or major credit card. If it becomes necessary to do clinical work outside the office, travel time will be charged at my standard applicable hourly rate.

CASE MANAGEMENT FEES: To avoid confusion and misunderstandings, please read this carefully. I do charge, on a pro-rated per minute basis, for all case management activities. Such activities include all non-billing and non-scheduling communications over ten minutes outside of normal session(s) via text, email, and phone. The pro-rated fee is based on the standard session fee, so case management will be pro-rated based on $120 per sixty minutes of time, or $2.00 per minute. Please note that for difficult cases like complex post-traumatic stress disorder (C-PTSD), Bipolar disorder, or borderline personality disorder, case management charges may become significant. If you become involved in legal proceedings that require my professional input, you will be expected to pay for my time even if I am ordered to court by another party.

COURT PROCEEDINGS:My preference is not to take time away from my clients to appear in court. However, if there is a situation that requires my involvement, you will be charged a minimum of $1500 for a half day (around $250/hour), and $2500 for the entire day. A subpoena means that you have agreed to these court costs, which are due prior to the set court date. Also, I require a one month notice to prepare and make adequate arrangements for already scheduled clients, since court appearances entail extensive time. Please note you will also be responsible for any attorney’s fees incurred in the process, including my own needed consultation to insure proper protection.

A $30 fee is assessed for each returned check or electronic transaction denied due to insufficient funds. If your account is unpaid for over 30 days, and other arrangements for payment in full have not been arranged, I reserve the option to use a collection agency, small-claims court, or directly bill your credit card to collect any owed fee(s). If such action becomes necessary, the costs of this action, if any, will be added to the principal of the debt.

Insurance Reimbursement: To protect your confidentiality, and to maintain the integrity of our professional treatment options, I do not do business with insurance companies. Depending on your insurance plan, you may be eligible for reimbursement for being treated by an Out Of Network Provider. An insurance Superbill will be provided for you upon request. It is your responsibility to submit this information.

5.CLIENT EXPECTATIONS: Session fees are for reservation of time and services. As a client seeking counseling, it is expected that you will be responsible for remembering and arriving promptly for your scheduled appointment. If you are going to be late or must cancel your scheduled appointment, it is expected that you will contact me with this information 24 or more hours prior to the session in question. You will be responsible for your full feeif 24+ hours notice is not given.Consideration will be given to legitimate illnesses, emergencies, or inclement weather. Sessions will end at the scheduled time, regardless of when it began. Repeated cancellations or no-shows may result in treatment termination.

6.PHONE PROCEDURES: To leave me a confidential message, call 720-432-8809. This account is password protected, and only I have access to this voice mail account. I will make every effort to return your call on the same day. Messages left after 8pm may be returned on the following day. You may also email me at:

I cannot guarantee that I will be able to respond to you immediately, and therefore I do not provide 24-hour phone coverage. In case of a psychological emergency, particularly one that is life threatening, you should go to your local emergency room and ask for the psychologist or psychiatrist on call. You can also dial 911 or the Denver Metro Crisis Line is open 24 hours a day 7 days a week at 844-493-TALK (8255).

7. TERMINATION: If you have not scheduled a session or have been out of contact with me for more than 6 months, I will make an effort to contact you. If I receive no reply, you will be considered an inactive client and your file will be closed unless we have discussed otherwise. You are welcome to reinstate at any time in the future. Please note, however, that you will be subject to any changes in session rate that may occur.

Please also note that I have an ethical duty to terminate with you if I believe that you are not sufficiently benefiting from the treatment and/orI believe that you need a different level or kind of care.

8. VACATION: In the event that I will be out of phone/email range for an extended amount of time, I will notify you, and another therapist with a similar orientation will cover my practice. That therapist’s contact information will be made available to you.

9. ELECTRONIC COMMUNICATION:It is impossible to assure privacy of any communication by electronic means. If you are uncomfortable with this possible limitation to your privacy, please communicate by other means. It is recommended that you only communicate via email and text for the purpose of scheduling, billing, or incidental matters, and use phone calls for any potentially sensitive issues.

E-mail transmission cannot be guaranteed to be secured or error-free as information could be intercepted, corrupted, lost, destroyed, arrive late or incomplete, or contain viruses. The sender therefore does not accept liability for any errors or omissions in the contents of this message, which arise as a result of e-mail transmission. Although e-mails and any attachments are believed to be free of any virus or other defect that might negatively affect any computer system into which it is received and opened, it is the responsibility of the recipient to ensure that it is virus free and no responsibility is accepted by the sender for any loss or damage arising in any way in the event that such a virus or defect exists.

My laptop is equipped with a firewall, a virus protection and a password, and all confidential information from my computer is backed up on a regular basis onto an encrypted hard-drive. Please notify me if you decide to avoid or limit, in any way, the use of email, texts, cell phone calls, phone messages, or e-faxes. If you communicate confidential or private information via unencrypted email, texts or e-fax or via phone messages, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted.

The following forms of communication are approved for use by Misha Grodt when contacting me:

Please initial each approved form of communication. Phone ______

Text ______

Email ______

Mail ______

Video conferencing ______

I, the undersigned(s) voluntarily consent to mental health and/or consultative services with Misha Grodt, MA, LPC. I, the undersigned(s), have read and understand the preceding information. I've also been provided with electronic or hard copies of the HIPAA NOTICE OF PRIVACY PRACTICES.

I understand my rights and responsibilities as a client or as the client’s responsible party.

I the undersigned(s) understand and agree that I am responsible for all fees relative to the professional services rendered under thisAgreement. I may terminate my responsibility under this agreement by paying my account in full and giving notice to the psychotherapist.

This document may periodically be changed or amended to comply with legal and professional standards. Updated versions of this document will be made available on my website at:

I attest that I am not a Medicaid recipient. In the event that I should apply for, or be accepted to Medicaid, I will notify Misha Grodt, MA, LPC immediately. ______(initial)

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Client’s Printed Name

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Client’s Signature Date