Jill Alexander, MA, MS

720.822.6863

REGISTERED PSYCHOTHERAPIST- PATIENT SERVICES AGREEMENT

Welcome to my practice. This document contains important information about my professional services and business policies. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us. You may revoke this agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.

Except in emergency situations, or where psychotherapy is being administered as the result of a court order, every licensed or unlicensed psychotherapist shall provide the following information in writing to each client during the initial contact.

Jill Alexander

License: Colorado # NLC.0104895

Undergraduate Degree: Psychology

University of Colorado, Boulder, Colorado 2000

Graduate Degree’s: Master of Education, 2005

Master of Counseling, 2016

University of Phoenix

The Colorado Department of Regulatory Agencies has the general responsibility of regulation the practice of licensed psychologists, licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists, certified school psychotherapists and unlicensed individuals who practice psychotherapy. The agency with the department that has the responsibility specifically for licensed and unlicensed psychotherapists is:

Board of Registered Psychotherapists

1560 Broadway, Suite 1350, Denver, CO 80202

(303) 894-7800

  • Registered psychotherapist is a psychotherapist listed in the State's database and is authorized by law to practice psychotherapy in Coloradobut 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.
  • Certified Addiction Counselor I (CAC I) must be a high school graduate, complete required training hours and 1,000 hours of supervised experience.
  • Certified Addiction Counselor II (CAC II) must complete additional required training hours and 2,000 hours of supervised experience.
  • Certified Addiction Counselor III (CAC III) must have a bachelor’s degree in behavioral health, complete additional required training hours and 2,000 hours of supervised experience.
  • Licensed Addiction Counselor must have a clinical master’s degree and meet the CAC III requirements.
  • Licensed Social Worker must hold a master’s degree in social work.
  • 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.
  • Licensed Clinical Social Worker, 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.

APPOINTMENTS

I schedule appointments as 50 minute sessions (one appointment hour of 50 minute duration). Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation and 48 hours advanced notice if you make a cancellation over a weekend for the following business day. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. When possible, I will try to find another time to reschedule the appointment.

PROFESSIONAL FEES

My hourly fee is $90.00 for individuals and couples. All payments will be made in full before each session begins. I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs. Because of the difficulty of legal involvement, I charge $180.00 per hour for preparation and attendance at any legal proceeding.

If you are divorced or going through a divorce, I must have both parents’ permission to see the child(ren) for counseling services. I DO NOT split payments between parents. All payments must be rendered at time of service and be agreed upon by both parents.

CONTACTING ME

It is likely you may receive my confidential voice mail if trying to reach me. I check my messages several times a day and will try to get back with you within 24 hours, excluding weekends and holidays. Should I be unavailable for an extended period of time, I will provide the name of another therapist covering for me. If your situation is life threatening, call 911 or your family physician, or go to the nearest emergency room. Telephone calls in excess of 10 minutes will be prorated at my fee of $90 per hour. My cell phone will be charged at a rate of $1 per minute.

BILLING AND PAYMENTS

You will be expected to pay for each session at the time it is held. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/ her name, the nature of services provided, and the amount due. (If such legal action is necessary, its costs will be included in the claim.)

DUAL RELATIONSHIPS: Not all dual relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs objectivity, clinical judgment, or therapeutic effectiveness or can be exploitative in nature. If it is necessary, I will assess carefully before entering into non-sexual and non-exploitative dual relationship with clients. In general, I will avoid creating any type of dual relationship with a client. I will never acknowledge working therapeutically with anyone without your written permission. Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it and often it is impossible to know that ahead of time. If for some reason, a dual relationship inadvertently occurs, it is your, the client’s, responsibility to communicate to me if the dual relationship becomes uncomfortable to you in any way. I will always listen carefully and respond accordingly to your feedback and will discontinue the dual relationship if I find it interfering with the effectiveness of the therapeutic process or the welfare of you the client and, of course, you can do the same at any time.

CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client's) written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the Disclosure Statement that you received with this form.

When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; and where a client presents a danger to self, to others, to property, or is gravely disabled.

When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by this therapist. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Jill Alexander will not reveal information regarding couple/child therapy unless BOTH parties are willing to sign a Release of Information. Jill Alexander will not release records to any outside party unless she is authorized to do so by all adult family members who were part of the treatment. She will release information regarding any individual who can give a release for information regarding their experiences in therapy.

By signing the Agreement, you agree that you have received a copy of the service agreement and were made aware of my professional services and business policies of my practice. This agreement has also been provided verbally and you understand your rights as a client or client’s responsible party.

REGISTERED PSYCHOTHERAPIST- PATIENT SERVICES AGREEMENT

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Signature of Client or Responsible Party Date

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If signed by responsible party, please state relationship to client and authority to consent

______Jill Alexander, MA, MS