DORA Disclosure Statement

Client Name*

First NameLast Name

Client Date of Birth*

Date

Client ID

Primary Therapist*

First NameLast Name

Primary Therapist Credentials*

License #1 (if applicable)

License #2 (if applicable)

Certification Number (if applicable)

The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of licensed psychologists, licensed social workers, licensed professional counselors, licensed marriage and family therapists, licensed school psychologists practicing outside the school setting, unlicensed individuals who practice psychotherapy, and certified/licensed addiction counselors.

The agency within the Department that has responsibility specifically for licensed and unlicensed psychotherapists is the:

Department of Regulatory Agencies, Mental Health Section, 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.

As your therapist, I have checked the description(s) that pertain to me:

Licensed Social Worker - The Licensed Social Worker must hold a masters degree in social work.LCSW, LMFT, LPC - Licensed Clinical Social Worker, aLicensed Marriage and Family Therapist, and a Licensed Professional Counselormust hold a Master’s degree in their profession and have two years ofpost-masters supervision.Licensed Psychologist - A Licensed Psychologist must hold adoctorate degree in psychology and have one year of post-doctoral supervision.Candidate - Psychologist Candidate, a Marriage and Family Therapist Candidate, Clinical Social Worker 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.Unlicensed Psychotherapist - 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.Certified Addiction Technician - Certified Addiction Technician (CAT) must have HS/GED and must complete 1,000 hours of supervised experience.Certified Addiction Specialist - Certified Addiction Specialist (CAS) must have bachelor's degree in Behavioral Health specialty and complete 2000 hours of supervised experience.Licensed Addiction Counselor - Licensed Addiction Counselor must have a clinical master’s degree and meet all of the requirements of CAS.Intern - Intern in the process of completing a Master’s degree in counseling, human services, or social work.

Client Rights and Important Information

1. You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy (if I can determine it), and my fee structure. Please ask if you would like to receive this information.

2. You can seek a second opinion from another therapist or terminate therapy at any time.

3. 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, Mental Health Section.

4. Generally speaking, the information provided by and to a client during therapy sessions is legally confidential if the therapist is a licensed marriage and family therapist, a licensed social worker, a licensed professional counselor, a licensed psychologist, an unlicensed psychotherapist, or certified/licensed addiction counselor. If the information is legally confidential, the therapist may not disclose the information without the client’s consent, except as provided in the confidentiality of the Mental Health Statute (C.R.S. § 12-43-218), the HIPAA Notice of Privacy Rights you were provided, and certain other legal exceptions. You should be aware that provisions concerning the disclosure of confidential communications do not apply to any delinquency or criminal proceedings, except as provided in C.R.S. § 13-90-107. I will identify any exceptions to you if any such situation arises while the therapeutic relationship exists or after we have terminated the therapeutic relationship.