Clinician Disclosure and Policy Statement Colorado State Law requires me to tell you: My Credentials: Master of Social Work, University of Minnesota, 1988; BA, College of St. Catherine, 1981, Theology. Doctor of Ministry (DMin) in pastoral counseling, Graduate Theological Foundation, 2014. Colorado License: LCSW 989689. Colorado Department of Regulatory Agencies regulates the practice of licensed psychotherapists, including clinical social workers. If you have a complaint we cannot resolve, you may contact the Board of Social Work of the Mental Health Licensing Section of the Division of Professions and Occupations, 1560 Broadway, Suite 1350, Denver, CO 80202, phone 303-894-7800. I hold a Master of Social Work degree, a post-college 2 year professional degree in counseling and mental health, including 18 months of clinical training in counseling clinic and hospital settings. I earned a Licensed Clinical Social Worker in 1990, after my first 2,000 hours of supervised counseling experience and passing a state examination. I have worked as a psychotherapist since 1988. My training is in psychiatric (“clinical”) social work and pastoral counseling. In the list below, I am required to tell you about each type of mental health counselor, below. My status is in bold. 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 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. Client Rights: You are entitled to information about my methods/techniques of therapy, anticipated length of therapy and fee structure. You can seek a second opinion or end therapy at any time. In a professional relationship such as ours, sexual intimacy between therapist and client is never appropriate and should be reported to the Board cited above. Information you tell me is private and legally confidential, generally speaking. I cannot be forced to release your information without your consent, including in a court of law. There are exceptions to confidentiality, such as in a life-threatening emergency when my clinical judgment deems it essential for your or another’s safety. I will explain exceptions if they arise. See Colorado Statute section 12-43-218, C.R.S. for more information. Colorado law also requires me to inform you: Any person who alleges that a mental health professional has violated the mental health practice act related to the maintenance of records of a client eighteen years of age or older must file a complaint or other notice with the licensing board within seven years after the person discovered or reasonably should have discovered the misconduct. Your mental health records may not be maintained after seven years from the date of termination of social work/psychotherapy or date of last contact, whichever is later. When the client is a child, the records will be retained for a period of seven years commencing either upon the last day of treatment or when the child reaches eighteen years of age, whichever is later, and I may not retain the records for more than twelve years. Note: I keep records for up to 10 years after our termination or last session, or after age 18 or a minor client. Your new provider may call, FAX, or email me for records to be sent to their office. Client Responsibilities: Payment of fees is expected at each session. My fee for one hour is $125, unless we have made other arrangements or are using insurance. I accept credit, debit, HSA cards only. I no longer can accept cash or checks. You agree to input your card info into a HIPAA-compliant and secure service called IvyPay, which allows me to charge your card without seeing its data, and to keep this info on file until termination of services. You agree to allow me to charge this card in the event of missed appointments, see below. I charge $75 for cancellations less than 24 hours before an appointment unless you are ill or have an emergency. Financial agreement for Group therapy: if you are registered for a therapy group, you agree to pay for each session offered, whether or not you attend, until you formally terminate. Missed group meetings are charged at the full rate your insurance has set, not your copayment rate. I charge my hourly fee on a pro-rated basis for time I spend preparing documents, appearing on your behalf at out-of-office meetings, and for phone therapy or case management over 10 minutes. Court expert testimony: if your attorney and you request my presence in court on your behalf, you/your attorney agree to pay my full $125 /hour rate door-to-door. You agree not to expect my appearance in court on your behalf without your attorney and I having discussed whether or not I can be of service to your case. You agree not to request my testimony on your behalf if I have provided conjoint therapy to you and your domestic partner/spouse. In an emergency: Call 911 or go to your nearest emergency department if you are in danger of death or injury. In other urgent matters, call me and leave your name and phone number. Allow an hour or longer for me to get back to you. If I will be on vacation, my phone greeting will name a back-up therapist you may call. Please sign below that you have received, understand, and agree to abide by my practice policy (if reading this online, please complete this information there and submit it to me directly from my site, which is protected using my HIPAA-compliant email service, called Hushmail). If you do not understand this document, we will discuss it in our intake session. Minor-age clients: Parents/Guardians signature also required below. If parents are divorced, both must sign, unless you provide me with documentation that you alone have legal custody. I understand and agree to the above information about Colorado law governing therapy practice, and Laura A Thor’s office policies: Client electronic Signature*Must be legal nameDate*Date of signature Preferred nameElectronic signature of legal guardian or parentFor minor clients under 18DateDate of signature Electronic signature of legal guardian or parentIf parents are divorced, both must sign, unless you provide me with documentation that you alone have legal custody.DateDate of signature Please provide the following information:Name First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Email* Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Preferred phone*Is it ok to leave a message?*ok to leave a message?YesNoAlternate PhoneContact Preference*how to contact meMailEmailPhoneEmergency Contact:Name* First Last Relationship*Phone*Physician/Psychiatrist:(I will not contact them without written consent except in emergency)Name First Last PhoneMedicationsGoals for your therapy?Anything you want me to know? Questions?PhoneThis field is for validation purposes and should be left unchanged.