ALPINE CONNECTION COUNSELING

Alpine Connection Counseling

Informed Consent

325 2nd Street, Suite H, Monument, CO 80132 (719) 233-TEEN (8336)

 Client Rights
 

To Confidentiality
 

Everything we discuss in counseling is legally confidential. This also means I cannot approach you in public unless you approach me first. Some sessions may be audio/video taped for the protection of the client and the therapist and will adhere to all your legal rights of client confidentiality.
 

Exceptions to confidentiality
 

Imminent harm to yourself or others; if I suspect any sexual or physical abuse of children; grave disability; if your records were subpoenaed by the courts; third-party billing and or insurance statements; or threat to national security.
 

Exception unique to Alpine Connection Counseling
 

Sometimes meeting in out-of-office locations can be beneficial for adolescents who are resistant to the traditional counseling setting. This is a unique and intentional approach of Alpine Connection Counseling that is provided as an option when agreed upon by the parent(s). This approach does, however, present risks to confidentiality due to meeting in public locations. For appropriateness, transportation will only be provided for same gender clients.  (by signing this document you are agreeing to take no legal action regarding confidentiality as it relates to the above specific exception.)
 

To understand your therapist's approach, methods, and therapy options please visit:

www.alpineconncetion.org
 

To report any grievances you may have against your therapist:
 

*Sexual contact between a therapist and their client is illegal in the state of Colorado and is not recognized as any form of therapy.

Contact: Colorado State Department of Regulatory Agencies, Mental Health Section, 1560 Broadway, Suite 1340, Denver CO 80202, or phone: 303-894-7766.

 

 To know your therapist's training and credentials:

Christian T. Hill has a Masters Degree in Community Counseling from the University of Northern Colorado and a BA in Communications from Stephen F Austin State University. Christian is a registered unlicensed psychotherapist in the state of Colorado and has been in private practice with excellent standing for over 15 years.

 Financial arrangements

 

The pricing of Alpine Connection Counseling and Christian T. Hill, MA is based off a level of experience, expertise, and involvement in finding solutions for you and your family that go beyond the traditional 1 hour therapy model.

 

Christian see’s a limited number clients and offers a level of a care that is relational yet assertive in finding a successful treatment plan that helps families navigate a very challenging process but which intentionally becomes more affordable over time. As the client improves there are lower price points for the client to stay involved in further care is needed although the ultimate goal is to empower a client to be fully independent and not need counseling.

Cancellation – you must cancel your appointment 24 hours prior or you will be charged the full amount.

 The agreed cost for therapy will be $165.00 per session which will last for 50 minutes (an additional 10 minutes will be spent on therapy notes, referrals, and assessments), or $95 for a 30 minute session, and $95 50 minutes phone/skype/facetime session.

I understand that if total payment is not received within a 30 days, that I the client am responsible not only for the outstanding balance due, but additionally any costs incurred to Alpine Connection Counseling from collection fees and all legal fees.  I understand that Alpine Connection Counseling does not accept insurance and that reimbursement is to be handled between the client and their own insurance company.

 Release of Liability
 

Because Alpine Connection Counseling LLC offers out-of-office counseling opportunities as an effort to reach and connect with hard to reach teens, this additional waiver is needed on sessions provided outside the traditional office setting in which other potential risks could occur.

By signing below, I assume any risk and take full responsibility and waive any claims of personal injury, death or damage to personal property associated with Alpine Connection Counseling LLC activities and events organized by Alpine Connection Counseling LLC. I understand and confirm that by signing this WAIVER AND RELEASE I have given up considerable future legal rights. I have signed this Agreement freely, voluntarily, under no duress. My signature is proof of my intention to execute a complete and unconditional WAIVER AND RELEASE of all liability to the full extent of the law for the benefit of Alpine Connection Counseling LLC, it’s employee’s, members, managers, and agents. I am 18 year of age or older and mentally competent to enter into this waiver and have legal guardianship to consent to this release from liability.

Family Information

Our family has a history of:
If your child meets criteria for a mental health condition, are you willing to consider medication?

Other Resources

Would your child benefit from our teen support group? ($50 per week 7pm on Thursday night)
Would the parent(s) be interested in our parents support group? (Tuesday nights 7pm $50 per week?)

Parent Signature

Signature of Therapist

Alpine Teen Counseling Center