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Disclosure & Informed Consent

Please complete and electronically sign the below form prior to your first appointment.

Shelli Myles, LPC. M.A. holds a Master of Arts degree in Counseling and a Bachelor of Science degree in Human Resource Management with a minor in Psychology. She is a licensed professional counselor in Colorado through the Dept. of Regulatory Agencies and is currently a member of the American Counseling Association (ACA) as well as the International Society for Neuroregulation and Research (ISNR). She worked with Rocky Mountain Memory Center in Ft. Collins, Colorado and was also an inpatient psych counselor for 4 years. She trains individuals as well as groups in Mindfulness therapy. Shelli has been practicing counseling and Neurofeedback for over 8 years and has worked with individuals experiencing ADHD, Depression, TBI, Autism, Anxiety, Learning disabilities, etc.

 

 

REGULATION OF PSYCHOTHERAPISTS – Colorado DORA Disclosure

The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations.  The regulatory boards can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.  The regulatory requirements for mental health professionals provide that 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 and have two years of post-master’s supervision.  A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision.  A Licensed Social Worker must hold a master’s degree in social work.  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, and complete required training hours and 1000 hours of supervised experience.  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.

 

  1. CLIENT RIGHTS AND IMPORTANT INFORMATION

 

  • You are entitled to receive information from me about my methods of therapy, the techniques we use, and the duration of your therapy. Please ask if you would like to receive this information. Our fee for each neurofeedback session is $100. Our fee for pre and post QEG’s $700. We offer discounts/packages via our website.

  • 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 a client is never appropriate. If sexual intimacy occurs, it should be reported to the Department of Regulatory Agencies.

  • Information provided by and to a client in a professional relationship with a psychotherapist is legally confidential, and the therapist cannot disclose the information without the client’s consent. There are several exceptions to confidentiality which include: (1) I/We are required to report any suspected incident of child abuse or neglect to law enforcement; (2) I/We are required to report any threat of imminent physical harm by a client to law enforcement and to the person(s) threatened; (3) I/We are required to initiate a mental health evaluation of a client who is imminently dangerous to themselves or to others, or who is gravely disabled, as a result of a mental disorder; (4) I/We are required to report any suspected threat to national security to federal officials; and (5) I/We may be required by Court Order to disclose treatment information.

  • Under Colorado law, C.R.S. § 14-10-123.8, parents have the right to access mental health treatment information concerning their minor children, unless the court has restricted access to such information. If you request treatment information from me, I may provide you with a treatment summary, in compliance with Colorado law and HIPAA Standards.

  • The client shall provide at least 24-hour notice to his/her clinician when needing to cancel/reschedule an appointment. However, it is understood that emergencies happen, and we will work with the client to reschedule. Mind Balance Neurofeedback LLC, reserves the right to charge a client $10 for arriving late to their appointment and $50 when there is less than a 24-hour notice/cancellation, missed appointment, or is 15 minutes late (which may result in rescheduling), as this can affect other clients and the scheduling for that day.

2. DISCLOSURE REGARDING DIVORCE AND CUSTODY LITIGATION

 

If you are involved in divorce or custody litigation, my/our role as a therapist is not to make recommendations to the court concerning custody or parenting issues.By signing this Disclosure Statement, you agree not to subpoena your therapist to court for testimony or for disclosure of treatment information in such litigation; and you agree not to request that your therapist write any reports to the court or to your attorney, making recommendations concerning custody.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 interests of the family’s children.

 

I have read the preceding information and understand my rights as a client/patient.  I also acknowledge that I have received a copy of this Disclosure Statement.

RIGHT TO CONFIDENTIALITY:

All client information and records are secured and kept confidential according to HIPPA regulations and the ACA ethical codes. If Mind Balance Neurofeedback or the counselors/technicians/coaches see clients in public settings, they will refrain from acknowledging them to protect client privacy. However, clients are welcome to initiate contact in public settings.

The following items are particularly important and require special emphasis. Please initial each of the following items:

I have had sufficient time to read the foregoing statement to allow me to fully understand it and/or to have any uncertainties clarified before signing.

 

I understand that there are usually significant improvements but that improvements in any individual case cannot be guaranteed and depends on the willingness of clients to commit themselves to treatment and actively participate during the Neurofeedback sessions. I further understand that some people do not improve, becoming worse before they become better, or may even, in rare cases, find their problems have worsened. I am willing to accept these risks.

 

I have familiarized myself with the “Brain Health” information and I understand that practicing good brain health in the areas of diet, exercise, sleep, work, and relationship habits are important for the success of my Neuro-conditioning treatment.

 

I understand that psychotherapy or coaching, in addition to Neuro-conditioning, from a qualified psychotherapist or certified professional coach may be required as a condition to receiving Neuro-conditioning services; and that this requirement may arise after treatment has begun, and that Neuro-conditioning may need to be stopped until arrangements can be made.

 

I understand that all my information will be kept confidential, and that my name and identifying information will not be shared with anyone without my written permission.

 

I understand that Neuro-conditioning is considered to be a relatively new treatment (although well-supported in the current literature) and some in the medical community and insurance companies may still consider it to still be experimental. I understand that it is not likely that insurance will provide benefits for any of the services provided. I hereby release Mind Balance Neurofeedback LLC, QEEG Neurofeedback and/or any of their sources of supervision, from any liability related to me/my child’s Neuro-conditioning treatment and agree to hold them, and/or their sources of supervision, harmless from any effects caused directly or indirectly from Neuro-conditioning and/or Neurofeedback.

 

I would like to receive text reminders of my appointments from Mind Balance Neurofeedback LLC and answers to questions I ask, and I understand that this mode of communication is not confidential or secure.

 

I agree to provide at least 24-hour notice to my clinician when needing to cancel/reschedule an appointment. However, it is understood that emergencies happen, and we will work with the client to reschedule. Mind Balance Neurofeedback LLC reserves the right to charge a client $10 for arriving 10 minutes late to their appointment and $50 when there is less than a 24-hour notice/cancellation, missed appointment, or is 15 minutes late (which may result in rescheduling), as this can affect other clients and the scheduling for that day.

I HAVE READ THE FOREGOING “Informed Consent and Policies”, understand it, have clarified all uncertainties before signing, and agree to all the provisions stated herein. My signature below serves as my consent for Mind Balance Neurofeedback to provide Neuro-conditioning services for:

Thanks for submitting!