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Disclosure & Informed Consent ( 1 of 3 )

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. 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 10 years and has worked with individuals experiencing ADHD, Depression, TBI, Autism, Anxiety, Learning disabilities, etc.



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.




  • 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. A sliding scale is determined by each situation and what clients can afford.

  • 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.



  • 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.


  • This Informed Consent for Teletherapy contains important information concerning engaging in electronic psychotherapy or teletherapy. Please read this carefully and let me know if you have any questions. This consent shall only apply to clients physically within the State of Colorado seeking therapeutic treatment within the State of Colorado.


Benefits and Risks of Teletherapy

  • Teletherapy refers to the remote provision of psychotherapy services using telecommunications technologies such as video conferencing or telephone.  One of the benefits of teletherapy is that the client and therapist can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or therapist moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It can also increase the convenience and time efficiency of both parties.


Although there are benefits of teletherapy, there are some fundamental differences between in-person psychotherapy and teletherapy, as well as some inherent risks.  For example:


  • Risks to confidentiality.  Because teletherapy sessions take place outside of the typical office setting, there is potential for third parties to overhear sessions if they are not conducted in a secure environment.  I will take reasonable steps to ensure the privacy and security of your information, and it is important for you to review your own security measures and ensure that they are adequate to protect information on your end.  You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.  In addition, if you have a smart speaker or other smart home device in the area where sessions are being conducted, please turn off the voice activation on that device during the duration of our sessions as a precaution.


  • Issues related to technology.  There are risks inherent in the use of technology for therapy that are important to understand, such as: potential for technology to fail during a session, potential that transmission of confidential information could be interrupted by unauthorized parties, or potential for electronically stored information to be accessed by unauthorized parties. 


  • Crisis management and intervention.  As a general rule I will not engage in teletherapy with patients who are in a crisis situation.  Before engaging in teletherapy, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our teletherapy work.


  • Efficacy. While most research has failed to demonstrate that teletherapy is less effective than in person psychotherapy, some experienced mental health professionals believe that something is lost by not being in the same room. For example, there is debate about one’s ability when doing remote work to fully process non-verbal information.  If you ever have concerns about misunderstandings between us related to our use of technology, please bring up such concerns immediately and we will address the potential misunderstanding together.


Electronic Communications

  • I use a secure platform for teletherapy services.  You may be required to have certain system requirements to access electronic psychotherapy via the method we choose. You are solely responsible for any cost to you to obtain any additional/necessary system requirements, accessories, or software to use electronic psychotherapy.


  • I have a legal and ethical responsibility to make my best efforts to protect all communications, electronic and otherwise, that are a part of our teletherapy.  However, the nature of electronic communications technologies is such that I cannot guarantee that our communications will be kept confidential and/or that a third party may not gain access to our communications. Even though I may utilize state of the art encryption methods, firewalls, and back-up systems to help secure our communication, there is a risk that our electronic communications may be compromised, unsecured, and/or accessed by a third party.

  • The extent of confidentiality and the exceptions to confidentiality that I outlined in my Disclosure Statement/Informed Consent still apply in teletherapy.  Please let me know if you have any questions about exceptions to confidentiality.



  • I will not audio or video record any portion of our teletherapy sessions together without your express written consent.  By signing below, you also agree that you will not audio or video record any portion of our sessions, nor will you allow anyone else to do so.


Appropriateness of Teletherapy

  • If at any time while we are engaging in teletherapy, I determine, in my sole discretion, that teletherapy is no longer the most appropriate form of treatment for you, we will discuss options of engaging in face-to-face in-person counseling or referrals to another professional in your location who can provide appropriate services.


Emergencies and Technology

  • Assessing and evaluating threats and other emergencies can be more difficult when conducting teletherapy than in traditional in-person therapy.  In order to address some of these difficulties, I will ask you where you are located at the beginning of each session and before engaging in teletherapy services, I will ask that you identify emergency resources that are near your location that I may contact in the event of a crisis or emergency to assist in addressing the situation.  I may also ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency.

  • If the session cuts out, meaning the technological connection fails, and you are having an emergency do not call me back, but call 911, the Colorado Crisis Hotline at 844-493-TALK (8255), or go to your nearest emergency room. Call me after you have called or obtained emergency services.

  • If the session cuts out and you are not having an emergency, disconnect from the session and I will wait two (2) minutes and then re-contact you via the teletherapy platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, then call me on the phone number I provided you (303-506-1948).

  • If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time.



  • The same fee rates shall apply for teletherapy as apply for in-person psychotherapy. However, insurance or other managed care providers may not cover sessions that are conducted using electronic psychotherapy. If your insurance, HMO, third-party payer, or other managed care provider does not cover electronic psychotherapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to our engaging in teletherapy sessions in order to determine whether these sessions will be covered.

I, the client, having been fully informed of the risks and benefits of teletherapy; the security measures in place, which include procedures for emergency situations; the fees associated with teletherapy; the technological requirements needed to engage in teletherapy; and all other information provided in this informed consent, agree to and understand the procedures and policies set forth in this consent.


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


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 > Complete New Client Intake Form (Form 2 of 3)

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