CLIENT RIGHTS AND TREATMENT AGREEMENT

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This form is required by the state of Colorado. 

I. TRAINING AND EXPERIENCE

Mental Health Solutions is the independent private practice of John Eckenwiler, LMFT. 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 my fee structure. Please ask if you would like to receive this information. In addition, what follows is some information about my training and professional status:

Master of Arts in Marriage & Family Therapy, 1985, Abilene Christian University

Colorado state license #152, Marriage & Family Therapist, 1992

Training in clinical hypnosis (50 CEU hours, approved in the state of Florida)

Approved supervisor, American Association for Marriage and Family Therapy, 1995-1998, 2002-present

You can seek a second opinion from another therapist or terminate therapy at any time. In a professional relationship (such as ours), sexual intimacy between a therapist and client is never appropriate. If sexual intimacy occurs, it should be reported to the State Grievance Board.

II. CONFIDENTIALITY

Generally speaking, the information provided by and to a client during therapy sessions is legally confidential, meaning the therapist cannot be forced to disclose the information without the client's consent. There are exceptions to this general rule, as in a criminal or delinquency hearing under court order, if you pose a serious physical threat to yourself or another person, evidence of physical or sexual abuse, or evidence that a child, incompetent or disabled person is suffering because of neglect. These situations will be identified if and when they arise in therapy. Please be advised that these exceptions are mandated by state law, therefore I will have no choice about reporting these situations to the appropriate person or agency should they arise. In cases of abuse or neglect, proof is not required, only evidence suggesting it may have occurred --- state law mandates these cases be reported.

Additionally, the state of Colorado defines a minor as someone under the age of 15 for counseling purposes. Sessions held with someone 15 or older are confidential (even if living with parents) and such a client has the right to treatment with or without the consent of the parents (and a separate fee agreement must be discussed to that person). This will be discussed if the parents have an unpaid balance on the account.

III. CONSENT FOR SUPERVISION AND REVIEW AND DISCLAIMER

From time to time, it is not uncommon for a therapist to seek supervision or consultation from a professional colleague or clinical supervisor. In addition, insurance companies typically require some clinical information to authorize treatment, and you will be asked to sign a release form to share this information. In both instances, all information will be kept in the strictest confidence with that professiona, colleague or supervisor. Therapy is a process requiring your effort and there can be no guarantee of specific results.

IV. REGULATION

The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of licensed and unlicensed mental health professionals. For questions, concerns or complaints regarding the practice of psychotherapy the agency within this department to contact is:

State Grievance Board, 1560 Broadway, Suite 1340, Denver, Colorado, 80202, (303) 894-7766.

V. FEES

You will be provided with a separate fee agreement which outlines what to expect and your financial responsibilities for treatment. You have the right and are encouraged to ask whatever questions you may have about payment for services.

VI. EMERGENCIES

The phone number used to reach John Eckenwiler, LMFT is a voice mail pager and can be utilized during normal working hours and often (but not always) during off-hours. If you have a life-threatening emergency after hours, you should call and leave a voice message for John Eckenwiler, then either call 911 or go directly to your nearest emergency room.

I have read the preceding information, understand my rights as a client and give my consent for supervision or review of my situation as outlined above.

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Client Signature Date

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Client Signature (any adolescent age 15 or older)