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Client Rights and Responsibilities Form

Janet Curry is a licensed professional counselor in Durango, Colorado who provides counseling services focused on mindfulness, stress reduction, and self-discovery. She received her master's degree in counseling in 2006 and has been practicing privately since 2007. Her approach integrates mindfulness-based stress reduction techniques. This disclosure statement outlines her credentials, counseling approach, client rights and responsibilities, confidentiality policies, fees, and emergency contact information. Clients must sign acknowledging they understand their rights.

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Julius Yves Dulfo Bagacay
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108 views2 pages

Client Rights and Responsibilities Form

Janet Curry is a licensed professional counselor in Durango, Colorado who provides counseling services focused on mindfulness, stress reduction, and self-discovery. She received her master's degree in counseling in 2006 and has been practicing privately since 2007. Her approach integrates mindfulness-based stress reduction techniques. This disclosure statement outlines her credentials, counseling approach, client rights and responsibilities, confidentiality policies, fees, and emergency contact information. Clients must sign acknowledging they understand their rights.

Uploaded by

Julius Yves Dulfo Bagacay
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Janet Curry, MA, LPC

Stillpoint Counseling & Mindfulness Training, llc


2243 Main Avenue, Ste. 4B
Durango, CO 81301
(970) 779-0611

COUNSELOR DISCLOSURE STATEMENT


Welcome to my practice. This document contains information about my professional services and
business policies, as well as information regarding your rights and responsibilities as a client.
Colorado law requires that I obtain your signature acknowledging that I have provided you with
this information. Please do not hesitate to ask any questions that you might have regarding this
information.

COUNSELING ORIENTATION, TRAINING, AND PROFESSIONAL


EXPERIENCE
Participating in counseling is a means of becoming more aware of yourself, your patterns of
thinking, feeling, and behaving, and of taking charge of your life. Many people seek counseling
for relief of the stress, pain, or suffering they are experiencing in their lives, be that on a physical,
mental, emotional or spiritual level. In my counseling practice, as in my personal life, I find that
stress, discomfort, or even pain can be powerful catalysts for positive change. When we can find
ways of bringing our full creativity, intelligence and compassion to the challenge of looking deeply
into our lives, counseling becomes the beginning of a life-long process of self-reflection, self-
discovery and liberation from confining definitions of self, others and the world.

I received my Master of Arts degree in Mental Health Counseling in June, 2006 from Seattle
University, and my B.A. from Williams College in 1985. I worked as a psychotherapist intern in
the Adult Outpatient Team at the Community Psychiatric Clinic in Seattle from 2005-2006. I
opened my private practice in Durango, CO in early 2007. I received my license as a
professional counselor in Colorado in March, 2011.

In addition, I have completed advanced professional training in an evidence-based health-care


program called Mindfulness-Based Stress Reduction (MBSR), developed by Jon Kabat-Zinn,
PhD, at the University of Massachusetts Medical School. This work is grounded in the practice of
paying attention from moment to moment without judgment, and is integrated into every aspect of
my counseling. I have been teaching MBSR classes since 2006, and offer them in Durango
several times per year. I am also a long-time, ardent student and practitioner of hatha yoga and
mindfulness meditation.

I see my role as supporting you in actively investigating, cultivating, and mobilizing your innate
potential for learning, growing, and healing, and for transforming personal suffering into a new
way of embracing life.

COLORADO REGULATORY RESPONSIBILITIES


The Colorado Department of Regulatory Agencies has the general responsibility of regulating the
practice of licensed psychologists, licensed social workers, licensed professional counselors,
licensed marriage and family therapists, licensed school psychologists practicing outside the
school setting, and unlicensed individuals who practice psychotherapy.

The agency within the Department that has responsibility specifically for licensed and unlicensed
psychotherapists is the Department of Regulatory Agencies, Division of Registrations, Mental
Health Section, 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.
CLIENT RIGHTS REGARDING TREATMENT AND IMPORTANT
INFORMATION
You have the right to receive information from me about my methods of therapy, the duration of
your therapy (if I can determine it), and my fee structure. Please ask if you would like to receive
this information. You also have the right to participate in setting treatment goals, to seek a
second opinion from another therapist, or to terminate therapy at any time. If you decide to
terminate therapy, I ask that you come in for at least one final session to wrap things up.

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 Department of
Regulatory Agencies, Mental Health Section.

CONFIDENTIALITY
Generally speaking, all information provided by and to a client during therapy sessions is legally
confidential and may not be revealed to others, or in any court of competent jurisdiction in the
State of Colorado, without your written consent, except where disclosure is required by law, as
listed in the Colorado Statutes (C.R.S. 12-43-218). Disclosure is required where there is a
reasonable suspicion that a child, elderly person, or disabled person is being abused. It may be
required when a patient presents a serious danger to themselves or others. It may also be
required as a part of a legal proceeding. At times, I consult with other professionals about client
issues, but do not use names, unless I have your written permission to do so.

APPOINTMENTS AND CANCELLATIONS


Appointments generally last for 50 minutes, though shorter or longer sessions can be arranged.
Please arrive on time to receive the full amount of your session time. Any phone consultation that
exceeds 10 minutes will be charged on a prorated basis. As I reserve scheduled appointment
times specifically for you, I ask for a minimum of 48 hours notice for any non-emergency
cancellation and changes.

FEES
My fee is $90 for a counseling session. If any difficulties arise during the course of treatment
concerning ability to pay, I encourage you to discuss them with me so that appropriate
adjustments can be made. Payment is due for sessions at the time of service.

EMERGENCIES
If you need to contact me between sessions, my number is # 970-779-0611. I will do my best to
return messages on the same day, with the exception of weekends and holidays. If you are
unable to reach me in a timely manner and are experiencing an emergency, please call the
emergency room of your local hospital, or call 911.

At any time in our work together, please feel free to ask any questions you might have or for
additional information.

I have read the preceding information and understand my rights as a client.

___________________________________ _____________________
Client/Patient Signature Date

___________________________________ _____________________
Therapist Signature Date

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