Eap Intake Packet Tt 09

Michael Dawson, MA, LPC 13791 E. Rice Pl. Aurora, CO 80015 Colorado License No. 3862 303-481-4257

Lee Dudley, MA 8534 E. Homestead Rd. Parker, CO 80138 303-478-8734

EQUINE ASSISTED PSYCHOTHERAPY PROFESSIONAL SERVICES AGREEMENT Professional ethics and the Colorado State Law require that I disclose information to you at the initial therapy session. The practice of both licensed and unlicensed persons in the profession of psychotherapy is regulated by the Colorado State Department of Regulatory Agencies. Any questions, concerns, or complaints may be directed to the State Board listed below: Grievance Board 1560 Broadway, Suite 1370 Denver, CO 80202 303-894-7766 YOUR RIGHTS AS A CLIENT: 1. You are entitled to receive information about the methods of your therapy, the techniques used, the duration (if known) and the fee structure. Please ask if you would like to receive this information. 2. You may seek a second opinion from another therapist or you may terminate therapy at any time. 3. In a professional relationship, sexual intimacy between a client and a therapist is never appropriate and should be reported to the State Grievance Board. 4. Generally speaking, the information provided by a client during therapy sessions is legally confidential. EXCEPTIONS TO CONFIDENTIALITY: There are exceptions to the general rule of confidentiality, which are listed in the Colorado statutes (see Section 12-43-218, C.R.S. 1988). I will identify these to you should any such situation arise during therapy. RECORD RETENTION: All records about your counseling will be maintained in a secure place during your time of treatment. Only authorized persons will have access to them. Examples of others who may have access to all or part of your file include: Other therapists who would be consulted when necessary to ensure that I am providing you the best possible care, supervisors, office staff, and certain outside agencies when contracted to provide billing, transcription, or collection services. At the completion of your counseling, these records will be kept for a period of three years, and then destroyed. A summary of your treatment will be kept an additional four years and then destroyed. Copies of your file can be sent to a qualified professional only by written request from you. FEES AND PAYMENT: Fees are determined prior to the initial session. A sliding scale will be used to determine a lower fee when indicated by financial need. Payment is due at the time service is rendered, unless other arrangements have been agreed upon. Except for Medicaid and Tri Care, it is the client’s responsibility to file claims for insurance. You must pay when you attend your session, and then seek reimbursement from your insurance company. A properly coded statement will be provided for you to include with your filing. APPOINTMENTS: Appointments not cancelled by the close of business on the day prior to your scheduled appointment will result in your being charged the full fee for your scheduled session, except in cases of illness or emergency. TERMINATION: Termination will usually be agreed upon mutually, but you may terminate at any time. However, in a few special instances, therapy may be terminated though you wish to continue. These include failure to meet the terms of our fee agreement, a need for special services outside the scope of my competency or the terms of this agreement, or prolonged failure to make progress in our work together. Should this happen, the reason for termination will be discussed with you, and you will be referred to the most appropriate resource that can be found for you.

Michael Dawson, MA, LPC 13791 E. Rice Pl. Aurora, CO 80015 Colorado License No. 3862 303-481-4257

Lee Dudley, MA 8534 E. Homestead Rd. Parker, CO 80138 303-478-8734

EQUINE ASSISTED PSYCHOTHERAPY WAIVER AND CONSENT

WARNING: Under Colorado Law, an equine professional is not liable for an injury or the death of a participant in equine activities resulting from the inherent risks of equine activities, pursuant to Section 13-21199, Colorado Revised Statutes DRESSING FOR EQUINE ACTIVITY SESSIONS Dress appropriately for the weather and conditions in the horse environment. Wear well-fitting shoes that are adequate for support and protection. NO SANDALS, MULES, CROCS, OR OPEN TOES. ACKNOWLEDGEMENT OF RISK I, the undersigned participant, hereby agree to release, indemnify, and discharge Michael Dawson and Lee Dudley, Double T Stables LLC, or their staff, on behalf of myself, my children, my parents, my heirs, assigns, personal representatives and estate as follows:

1. I acknowledge the inherent risks which are involved in riding and working around horses. These risks may include, but are not limited to, damage to personal property, illness, bodily injury, trauma, or death resulting from a fall or while riding or being in close proximity to horses. 2. I further acknowledge that both horse and rider can be injured in the normal course of events while having contact with or caring for horses, including but not limited to such contact as is customary for equine assisted therapy or growth and learning activities, and therefore agree to indemnify and hold harmless Michael Dawson and Lee Dudley, Double T Stables LLC, and further release them from any liability or responsibility for any accident, injury, damage, or death to the undersigned or any property or horse the undersigned , or to any family member or spectator accompanying the undersigned while on the premises.

I have been informed of my rights as a client and my therapist’s training and qualifications, and consent to allow my therapist to share the content of our sessions with supervisors or consulting colleagues as necessary. I have also read the above information and understand my rights as a client. Acknowledge that I have read and understand the release of liability provisions, and I have included with this Professional Services Agreement and Equine Assisted Psychotherapy Waiver and Consent a signed copy of Facilities Agreement & Waiver for Double T Stables LLC. ____

Double T Stables LLC Facilities Agreement & Waiver Attached (Please check to indicate)

_________________________________ Print Name of Minor Child (1)

_________________________________________ Signature of Minor Child (if applicable)

_________________________________ Print Name of Minor Child (2)

_________________________________________ Signature of Authorizing Adult

_________________________________ Therapist Signature

___________________________________________ Date

Michael Dawson, MA, LPC 13791 E. Rice Pl. Aurora, CO 80015 Colorado License No. 3862 303-481-4257

Lee Dudley, MA 8534 E. Homestead Rd. Parker, CO 80138 303-478-8734

AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION I, ___________________________________________, authorize the release of agreed upon information concerning my status or treatment, for the coordination of care, equine therapy team participation, joint family sessions, or for any other reasonable purpose related to my care, to ___________________________________________________________________________________________________ Name Title/Role Phone/fax ___________________________________________________________________________________________________ Name Title/Role Phone/fax PHOTO AND VIDEO RELEASE Equine Assisted Psychotherapists sometimes use photographic or video images of parts of sessions for training, education, and informational purposes. Please indicate your preference below. By indicating “yes”, you grant unlimited permission for the use of photo or video images and waive all right and title to such images and their future use. ___________ NO, you may not take or use any photographs or videos of my sessions in any way. ___________ Yes, you may take limited photos or videos that show my face but don’t disclose my identity. This consent will automatically expire one (1) year after the date of my signature below, or such other date as specified: ____________________________________________________________, or until renewed, extended or revoked by client. I understand I have the right to refuse to sign this form, and that I may revoke my consent at any time (except to the extent that the information has already been released). _____________________/___________________________ Name of Minor Child / Signature of authorizing adult Extended until ________________________ Date

______________________ Date

_____________________/_____________________________ Name of Minor Child / Signature of authorizing adult