Stephanie (Bartlett) Goldstein, LPC, LMFT
2629 W. Main St. Suite 170 Littleton, CO 80120
720-360-7972 (phone), (888) 979-8719 (fax), www.stephaniebartlett.com
INFORMED CONSENT
Welcome to my practice! I am required by the State of Colorado and the Department of Regulatory Agencies to share the following information with you to help establish the understanding and trust essential to a therapeutic relationship. Please provide the requested information and read this document carefully, as it contains important information about my practice, policies, and how your mental health information can be used and disclosed. Please note any questions or concerns that you have. I invite you to discuss your questions or concerns with me at any time. After you sign the enclosed documents, they will constitute a binding agreement between you and Stephanie (Bartlett) Goldstein, LPC, LMFT.
Each client is required to sign this form. Any child under the age of fifteen (15) years of age must have a parent or legal guardian consent to the mental health services to be provided. Any child fifteen (15) years of age or older may sign the below form and consent to mental health services without the consent of a parent or legal guardian. If the parent or legal guardian is consenting to the mental health services, the required disclosures shall be made to the parent or legal guardian. If the child is consenting to mental health services, then the required disclosures shall be made to the child.
ABOUT YOUR THERAPIST:
Stephanie (Bartlett) Goldstein is licensed by the Colorado Department of Regulatory Agencies of Professional Counselors. She is a Licensed Professional Counselor (LPC) and a Licensed Marriage & Family Therapist (LMFT). Stephanie is also a certified trauma-focused equine-assisted psychotherapist (TF-EAP) and is a member of the International Association of Eating Disorder Professionals (IAEDP). Stephanie attained a Master’s Degree in Counseling from St. Edward’s University in Austin, Texas. Stephanie has worked with public and private mental health facilities including inpatient psychiatric care, residential care, and outpatient care. Her license numbers are as follows: CO LPC: 0011398, CO LMFT: 0001262.
ABOUT THERAPY:
Stephanie believes life’s challenges are opportunities for growth and acceptance rather than simply issues to fix. We all encounter difficult crossroads in life-loneliness, relationship struggles, anxiety, depression, low self-esteem, etc. Stephanie believes that such challenges in our lives are opportunities for us to learn more about ourselves, to heal, and to grow into the human beings we choose to be. As your therapist, part of Stephanie’s job is to help empower you to identify patterns in your life that are no longer working for you. Stephanie believes that you have all of the resources you need to heal yourself. She can be there to guide you in the discovery of those resources within yourself. Together, you and Stephanie can collaboratively work towards achieving your goals for therapy and beyond.
When working with children and adolescents, Stephanie employs not only talk therapy, but also creative play therapies. These might include playing games, drawing, music therapy, etc. Stephanie firmly believes that when working with children and adolescents, confidentiality is of utmost importance in order to build a trusting relationship. It has been Stephanie’s experience that children and adolescents most often only open up about what’s truly going on when they feel it is safe and confidential to do so. While parents legally have the right to view all of their children’s therapy notes, Stephanie encourages parents to express their concerns directly to her in order to open up a therapeutic discussion. Stephanie works on building children and adolescents’ sense of self and coping mechanisms in order to empower them to voice their feelings directly to their parents in a family session. Stephanie oftentimes role plays with children and adolescents in order to practice telling their parents about something sensitive if needed. However, as with adult clients, if children or adolescents express to Stephanie a desire to hurt themselves or someone else, Stephanie is required to break confidentiality and report such information in order to protect both the client and the intended victim.
Working with children and adolescents will, at some point, involve working with the parent(s) as well. Therefore, Stephanie may ask the parent(s) to schedule a session. Stephanie may also recommend a combination of individual sessions with the child or adolescent, co-parenting sessions with one or both parents, and family therapy sessions.
Stephanie is a firm advocate of individual, family, and group therapy as processes of change. However, it is important that clients understand the nature of the therapeutic process so that they will know what to expect. The following represent a partial list of answers to common questions and expectations. Please feel free to ask ANY questions that may arise.
1) Psychotherapy is a collaborative effort between you and the therapist. Your therapist only facilitates change; she cannot make changes happen.
2) The efficacy of psychotherapy (the power to produce results) is in the nature of the relationship between the client and the therapist. It is very important that you feel you have a comfortable and safe working relationship with your therapist. While this takes time, it also requires that the client be honest about their behavior and any concerns they may have about therapy or their therapist.
3) The change process can be uncomfortable.
A) The clients may have insights, memories or otherwise gain information that may
be unpleasant.
B) Clients may experience loss in relationships as they discover and change behavior.
C) Families and individuals often experience escalations in problems before they experience improvements.
D) Family members and significant others may be reactive to changes a client may make as a result of psychotherapy.
4) The therapeutic relationship is a very special professional relationship. While clients may develop a close emotional bond with the therapist, they need to understand that this does not include a social relationship or friendship.
5) Touch is an important aspect of therapy. Touch may be used to show support, acknowledgement and in greetings and salutations. Therapeutic touch should never be inappropriate or sexual. Stephanie will ask clients for permission to provide therapeutic touch. Clients need to inform Stephanie if they are in any way uncomfortable with therapeutic touch.
6) Confrontation is an essential element of psychotherapy. Clients can expect Stephanie to confront issues, behaviors and processes in as gentle and efficient manner as possible.
7) Stephanie believes that human beings live in relation to other human beings. Therefore with the client’s permission, family, friends and significant others may be requested to participate.
8) Stephanie is an experiential – process oriented therapist who uses techniques that are largely cognitive-behavioral, psychodynamic, experiential and structural.
SESSIONS:
Individual sessions are 45-55 minutes long. If a longer session time is needed, it should be scheduled ahead of time. The cost of that extended session will increase according to the length of time allotted. Usually sessions are scheduled weekly; however, sessions may occur more frequently in order to manage a crisis or less frequently to manage termination of therapy.
COMMUNICATION OUTSIDE OF THERAPY SESSIONS:
Because it is not possible to guarantee the confidentiality of email communications, please use discretion in deciding whether or not to communicate with Stephanie via email. Stephanie cannot be held responsible for any information lost in transit or viewed by a third party. Email should only be used for brief, general questions. Hence, emergencies, therapeutic issues, sensitive personal information, and cancellations should all be communicated to Stephanie over the telephone or in person. If you choose to communicate via email, you consent to Stephanie responding via email and assume all risks involved. Also, due to Stephanie being in sessions with clients throughout the day, please allow Stephanie up to 48 hours for a return email and up to 24 hours for a return phone call. Any messages left after 5pm on Friday will be returned on Monday. Stephanie will make every effort to get back with you in as timely a manner as possible. Stephanie believes healthy boundaries are important for every individual including herself. Therefore, if phone calls or emails to her become excessive, Stephanie will talk with you about it as this may indicate a need for more frequent sessions. Stephanie does not permit clients to text her due to lack of confidentiality.
RECOVERY RECORD:
As part of excellent service as well as enhanced continuity of care, Stephanie offers an interactional communication tool to some clients, if appropriate, called Recovery Record. Recovery Record is a HIPAA-compliant application. Recovery Record can be utilized for free expression of thoughts and feelings, food and exercise accountability, and completing homework tools that Stephanie may assign. Please note that Stephanie reviews all client logs once daily Monday-Friday. If you are feeling suicidal, please do not post it on Recovery Record for support; instead, please follow the Emergency protocol listed below.
LITIGATION LIMITATIONS:
If you are involved in a divorce or custody litigation, Stephanie’s role is not to make recommendations to the court concerning custody or parenting issues. The court can appoint professionals who have no prior relationship with family members to conduct an investigation or evaluation and to make recommendations to the court concerning parental responsibilities or parenting time in the best interest of your children.
EMERGENCY:
For non-emergency urgent matters, Stephanie can sometimes be reached via her cell phone at (720) 360-7972. If she is out of her office for extended periods of time (more than two days), she will let her clients know that she will be unavailable. In case of emergency, clients should call 911, call the 24-hour National Crisis Hotline at 1-800-273-TALK, or go to your nearest emergency room. If you require after hours emergency care, you are solely responsible for all costs arising from such care. Crisis evaluations are billed at $275/hour.
TERMINATION:
Client and therapist ideally mutually agree upon termination of the counseling/therapy relationship. Stephanie’s only goal is for her clients to be content with their direction in life or toward a solution and relatively confident in their skills and abilities to accomplish such.
The most common reason for ending therapy is that a client’s concerns have been addressed. You are entitled to end therapy or seek a second opinion from another therapist at any time. However, most clients find it helpful to have one or two sessions to bring closure to therapy and to discuss therapeutic progress. These sessions can be helpful in preventing future problems. Another scenario in which therapy ends is when a client’s challenges lie beyond the limits of your therapist’s ability to help. If it becomes apparent to your therapist at any point that your challenges lie beyond her expertise or ability to help, she is legally required to refer, terminate, or consult. She will discuss this with you, offer appropriate referrals, and end therapy. Termination of the counseling relationship will automatically occur if there has been no contact between client and therapist for three (3) weeks.
REFERRALS:
Stephanie sees clients by referral only. If you know of someone who may benefit from her services, please let her know. A referral is the highest compliment Stephanie can receive!
FEES:
The initial Evaluative session is $190.00. Individual, Couple, Co-Parenting & Family 50 minute office sessions are $130.00. The fees are paid as services are rendered unless special arrangements are made with the therapist.
Equine Therapy 50 minute sessions are $165.00.
Non-emergency therapeutic calls during business hours (Mon.-Fri. 8am-5pm, excluding holidays) lasting more than 10 minutes are billed pro-rated at the regular fee.
Skype and/or Facetime sessions are billed at the regular hourly rate.
Crisis phone calls after business hours that require a call back after business hours that do not result in a hospitalization evaluation are billed at $200/call. Crisis phone calls after business hours that require a call back after business hours that do result in a hospitalization evaluation are billed at $300/call.
Court documentation preparation, phone consultation with attorneys, or court appearances are billed at $375/hour plus expenses. Records will not be released if you have an outstanding balance.
Any non-legal related documentation preparation is billed at $30 per document.
All payments should be made directly to Stephanie (Bartlett) Goldstein, LPC, LMFT. Acceptable forms of payment are cash, check, or debit/credit card. If your check bounces, you will be charged an additional $10 to cover bank fees.
Please feel free to discuss financial arrangements. Every effort will be made to assist those who need and desire therapy.
CANCELLATIONS & NO-SHOWS:
Since your appointments involve the reservation of time specifically for you, and out of respect for Stephanie, a minimum of 24 hours’ notice is required for rescheduling or canceling an appointment. Anytime you do not attend a scheduled appointment without any notice of cancellation, you will be charged the full fee amount of your session. Please note that for sessions on Mondays, please cancel by Friday. Missed appointments are the financial responsibility of the client and are billed at full rate. Please note that insurance does not pay for missed appointments, so clients are directly billed. Repeated cancellations (more than two) without the required 24 hours’ notice may result in the termination of therapy. Multiple no-shows will result in the termination of therapy.
OVERDUE PAYMENT & BILLING:
If your account is more than 30 days overdue and suitable arrangements have not been agreed to, Stephanie may become obligated to turn past due accounts over to collection agencies or small claims court (if such legal action is necessary, the costs of bringing that proceeding will be included in the claim). Stephanie will provide the collection agency or Court with your Name, Address, Phone Number, and any other directory information, including dates of service or any other information requested by the collection agency or Court deemed necessary to collect the past due account.
PSYCHOTHERAPY:
Stephanie is committed to the highest standard of ethical practice in the field of mental health. The information provided by clients during therapy sessions is legally confidential, except as provided in section 12-43-218 of the Colorado Mental Health Statute, and except for certain exceptions that are identified in the Confidentiality section of this disclosure. In a professional relationship (such as psychotherapy), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs it should be reported to DORA at 303-894-7766, Mental Health Section, 1560 Broadway, Suite 1370, Denver, Colorado 80202.