9085 East Mineral Circle | Suite 235 | Centennial, Colorado 80112 | Phone 720.299.8342 | Email

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Information, Disclosure, and Consent

Welcome to my practice.  I appreciate the opportunity to provide you with psychological services and look forward to helping you reach your goals.  This document contains important information about my professional services and business policies and is provided to you in compliance with Colorado State Law.  If you have any questions about the information contained in this document, please ask and I will be happy to answer them for you.

Credentials

I am a licensed psychologist in the state of Colorado.  My license number is 2741.  I hold the following degrees:

B.A. in Psychology from the State University of New York at Albany, 1992

M.A. in Counseling and Guidance from New York University, 1994

M.A. in Clinical Psychology from the University of Denver, 1999

Psy.D. in Clinical Psychology from the University of Denver, 2000

Additionally, I completed my internship in Clinical Psychology in August 2000 at the University of Denver Counseling and Behavioral Health Center and my post-doctoral supervision hours at Colorado Assessment and Treatment Center.

The practice of licensed and registered professionals in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations.  The Board of Psychologist Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, or by phone at 303.894.2291.  A licensed psychologist must hold a doctorate degree in psychology, have one year of post-doctoral supervision, and pass state licensing requirements.  Regarding the regulatory requirements of other 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, have two years of post-master’s supervision, and pass state licensing requirements; a licensed social worker must hold a master’s degree in social work and pass state licensing requirements; 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, complete required training hours and 1000 hours of supervised experience, and pass licensing requirements; 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.

Client Rights

  • You are entitled to receive information from me about my methods of therapy, the techniques I use, the estimated duration of your therapy, and my professional fees.
  • You are free to seek a second opinion from another therapist or to terminate therapy at any time.
  • In a professional relationship such as ours, sexual intimacy between a therapist and client is never appropriate.  Such a violation should be reported to the Mental Health Licensing Section of the Division of Registrations. The Board of Psychologist Examiners is part of this system and can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, or by phone at 303.894.2291.
  • Generally speaking, the information provided by a client during therapy sessions is legally confidential.A written release of information with your signature is required in order for me to release or obtain information regarding your treatment.However, there are important exceptions to this general rule of confidentiality.These exceptions are listed in the Colorado statutes (C.R.S. 12-43-218) and the Notice of Privacy Practices you were provided and include criminal or delinquency proceedings, serious danger to self and/or others, grave disability, and instances of suspected child and/or elder neglect and/or abuse.

Treatment Philosophy

I utilize an integrative, individualized treatment approach, drawing from cognitive-behavioral, solution-focused, systems, and feminist theories.  As such, I believe in providing goal-directed treatment.  This means that we develop a treatment goal or several goals together, after a thorough assessment.  All treatment is then planned around progressing toward the achievement of the established treatment goal(s).  If you ever have questions about the nature of treatment or anything else about your care, please don’t hesitate to ask.

Financial Terms/Fee Information

My standard fee is $150 per session.  Sessions are generally 45 minutes long.  Payment is due at the time services are rendered.  Payment can be made in the form of cash, checks, debit cards or credit cards.  There will be a $25 charge for all checks returned due to insufficient funds.  If you have insurance coverage for mental health services and I am a participating provider of your insurance health plan, upon verification of health plan/insurance coverage, your insurance will be billed for you and I will be paid directly by the insurance carrier.  You will be responsible for any applicable deductibles and co-payments.  Co-payments must be paid at the time services are rendered.  If you are not eligible at the time services are rendered, you are responsible for payment in full.  If you have insurance coverage for mental health services and I am not a participating provider of your insurance health plan, you will need to check with your carrier about how to file a claim.  I will be happy to provide documentation of billing and payments as an out-of-network provider for your insurance needs.

Cancelled/Missed Appointments

A scheduled appointment means that time is reserved only for you.  If you are unable to keep a scheduled appointment, please notify me as soon as possible.  If an appointment is missed or cancelled with less than twenty-four hours notice, you will be billed directly according to the standard session fee or according to the rules of your health plan.  Your health plan does not cover payment for missed appointments; therefore, you are responsible for payment in full.

Late Arrivals

Sessions of late arrivals will end on time and be billed at the standard session rate.

Overdue Balances

Invoices will be sent at end of each month for any outstanding/overdue balances. Overdue balances not paid after 60 days are subject to an interest rate of 2% per month on the unpaid balance, unless previous arrangements for payment have been established and agreed upon. This interest charge is applied to the total unpaid overdue balance at the end of each month. Overdue balances not paid after 120 days may require utilizing the services of a collection agency to secure payment, which may require the disclosure of otherwise confidential information. In most collection situations, only information necessary to secure payment will be released (e.g., demographic information). If collection and/or legal action is necessary to secure payment, you will be responsible for the full amount of these costs and these costs will be included in the claim.

Telephone Calls

If you need to speak with me between scheduled appointments, please leave a voicemail message and I will return your call as soon as possible.  I do not charge for brief telephone conversations.  However, any telephone call that goes beyond ten minutes will be billed on a prorated basis based on the standard session fee.

Electronic Communication

Please be advised that email is not a secure method of private communication.  As such, it is advised that you do not send confidential information nor discuss clinical issues via email.  Email is also not an appropriate method of contacting me in the event of an emergency.  Please see emergency contact procedures as defined below.  Email may be used to contact me regarding appointment scheduling and/or other administrative and non-clinical issues.

Treatment Records Maintenance

Client treatment records will be maintained for seven years following the last date of service delivery for adults or until three years after a minor reaches the age of 18, whichever is later. After that period, treatment records will be destroyed in compliance with Colorado State Law. Any person who alleges that a mental health professional has violated the licensing laws related to the maintenance of records of an adult client must file a complaint or other notice with the licensing board within seven years after the person discovered or reasonably should have discovered the misconduct.

Emergency Procedures

If you experience a clinical emergency, please follow the emergency contact procedure outlined on my voicemail message, and I will return your call within one hour.  Please do this for true emergencies only.  In a life-threatening emergency or if you cannot wait for my return call, please call 911 or go to the nearest emergency department. 

Release of Information

I authorize the release of information regarding my treatment to my health plan/insurance carrier for the payment of claims, certifications/case management decisions, and other purposes related to the administration of benefits for my health plan. 

Consent for Treatment

I further authorize and request that my treatment provider carry out mental health examinations, treatments, and/or diagnostic procedures, which now, or during the course of my care, are advisable.  I understand that the purpose of these procedures will be explained to me upon my request and subject to my agreement.  I also understand that while the course of therapy is designed to be helpful, it may at times be difficult and uncomfortable. 

Consent

I have read and been advised verbally of my rights and responsibilities as a client.  I understand my rights as a client and agree to all of the information contained in this Information, Disclosure, and Consent form.  A copy of this information has been given to me for my records. 

________________________________________________________________

Client (or Guardian) Signature                                                      Date

_______________________________________________________________

Client (or Guardian) Printed Name                                                Date

_______________________________________________________________

Jennifer Ritchie-Goodline, Psy.D.                                                  Date



Current edition as of 8/16/18.

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Colorado Licensed Clinical Psychologist License #2741.  © Copyright 2006-2018 by Dr. Jennifer Ritchie-Goodline.  All Rights Reserved.

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