Mandatory Disclosure Statement

For Review Only

 
 

As Required to be signed prior to 1st session

  • A Registered Psychotherapist is a psychotherapist listed in the State’s database and is authorized by law to practice psychotherapy in Colorado, but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state. 
  • A Certified Addiction Counselor I (CAC I) must be a high school graduate or equivalent, complete required training hours and 1,000 hours of supervised experience. 
  • A Certified Addiction Counselor II (CAC II) must be a high school graduate or equivalent, complete the CAC I requirements, and obtain additional required training hours, 2,000 additional hours of supervised experience, and pass a national exam. 
  • A Certified Addiction Counselor III (CAC III) must have a bachelor’s degree in behavioral health, complete CAC II requirements, and complete additional required training hours, 2,000 additional hours of supervised experience, and pass a national exam. 
  • A Licensed Addiction Counselor must have a clinical master’s degree, meet the CAC III requirements, and pass a national exam. 
  • A Licensed Social Worker must hold a master’s degree from a graduate school of social work and pass an examination in social work. 
  • A Licensed Clinical Social Worker must hold a master’s or doctorate degree from a graduate school of social work, practiced as a social worker for at least two years, and pass an examination 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 Licensed Marriage and Family Therapist must hold a master’s or doctoral degree in marriage and family counseling, have at least two years post-master’s or one year post-doctoral practice, and pass an exam in marriage and family therapy. 
  • A Licensed Professional Counselor must hold a master’s or doctoral degree in professional counseling, have at least two years post-master’s or one year postdoctoral practice, and pass an exam in in professional counseling. 
  • A Licensed Psychologist must hold a doctorate degree in psychology, have one year of post-doctoral supervision, and pass an examination in psychology.

Degree and Certification:

A.A. Florida Community College at Jacksonville

Certified Rapid Transformational Therapist from Marisa Peer School

The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Professions and Occupations. The Colorado State Board of Registered Psychotherapists can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800

 

As a client you are entitled to information about the method of therapy, the techniques used, the duration of therapy, and the fee structure: 

Rapid Transformational Therapy (RTT) embraces many of the positive aspects of hypnosis and hypnotherapy that are known to produce a transformative effect on clients: the use of trance, regression and hypnotic conditioning.  However RTT goes beyond to truly empower clients. RTT aims to to deliver permanent change in a single 90 minute session. (Although some clients and some issues may require up to 3 sessions.) By using a technique called Role Function, Purpose, it honors and values the significance clients attach to their issues/problems they have been holding on to and then offers a significant emotional release that leads to freedom and transformation. The client works with the therapist in uncovering the meaning and interpretation of events and then changing them, as opposed to positive conditioning alone. This leads to permanent powerful change.

Epileptics should not enter hypnosis or anyone diagnosed as having a psychotic illness.

Rapid Transformational Therapy (RTT) is not intended to substitute for the diagnosis and care of a qualified physician nor to encourage the treatment of illness by persons not recognizably qualified. If you receive hypnosis and are under medical care for ANY condition do not make ANY adjustments to ANY prescribed medication without the approval of your doctor. If in doubt please seek advice from your physician.

Sessions run 60-90 minutes depending on age and whether regression is necessary.

Fees: Adult Session: $1299 | Child: $499 | 

Group Sessions (paid by organizer, or in advance)

As a client you are entitled to seek a second opinion from another therapist or may terminate therapy at any time. 

This is a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licensed, registers, or certifies the licensee, registrant, or certificate holder.

The information provided by you, the client, during therapy sessions is legally confidential in the case of licensed marriage and family therapists, social workers, professional counselors, and psychologists; licensed or certified addiction counselors; and registered psychotherapists, except as provided in § 12-43-218 and except for certain legal exceptions that will be identified by the licensee, registrant, or certificate holder should any such situation arise during therapy.

A registered psychotherapist is a psychotherapist listed in the state’s database and is authorized to practice psychotherapy in Colorado but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain registration from the state.

I have read the preceding information and understand my rights as a client or as the client’s responsible party.

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Print Client’s Name

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Client’s or Responsible Party’s Signature Date

If signed by Responsible Party, please state relationship to client and authority to consent:

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