Informed Consent

Suzanne Forrester, M.A., M.A.
Registered Psychotherapist
Colorado License #NLC.00896
1377 Tamarack Avenue
Boulder, CO 80304

Disclosure Statement Client Rights, Policies and Fees Thank you for choosing to work with me. The following is a description of your rights as a client, the policies of my practice, my background, training and fees. Please feel free to ask any questions about which you would like further clarification.

A registered psychotherapist in private practice for the past 14 years, I hold a Masterʼs degree in counseling psychology specializing in Wilderness Therapy from Naropa University and a Masterʼs degree in English from Ohio University.

Prior to opening my private practice in 2005, I spent 10 years working in therapeutic programs with adolescents, young adults and their families. As a faculty member at Prescott College and Naropa University, I have trained graduate students in the field of Wilderness Therapy.

I hold advanced training in evidence-based methods of resolving trauma and otherwise restoring health in couples and family systems. I am a certified PACT Level 2 Clinician (Psycho-Biological Approach to Couple Therapy) and a certified EMDR Level 2 therapist.

Your rights as a client: You are entitled to receive information about methods of therapy, techniques used, duration of therapy (if known) and fee structure. You may seek a second opinion from another therapist or terminate therapy at any time.

In a professional relationship, sexual intimacy is never appropriate and should be reported to the grievance board.

In Colorado, the practice of psychotherapy by both licensed and unlicensed persons is regulated by the State. Any questions, concerns or complaints regarding the practice of mental health professions may be directed to: The Department of Regulatory Agencies. www.dora.colorado.gov.

Generally speaking, the information provided by and to the client during therapy sessions is legally confidential and cannot be released without the clientʼs consent. There are exceptions to this confidentiality, some of which are listed in section 12-43-218 of the Colorado Revised Statutes, as well as other exceptions in Colorado and Federal law, and include known or suspected child abuse; the client is at risk of harming self or others; or the client has signed a release of information giving permission to release information to a specific individual or agency. Otherwise, information shared during therapy sessions is confidential. I practice under the supervision of Duane Mullner, licensed professional counselor, a master therapist. I may consult with him or other colleagues for professional support; however, your name and identifying details will not be used.

My Policies and Fees If a situation arises that necessitates your needing to re-schedule your appointment, I ask that you do your best to re-schedule with 24 hours notice (48 hours for day-long intensives) and I will do the same. For day-long intensives, I ask that you pay a deposit of one half up front, which is refundable should you need to reschedule. and I reserve the right to charge for missed appointments. Payment is expected at the time of service unless other arrangements have been made.

My fee is $1200 for a day-long couple or family intensive. On-going work is $180 for a 50-minute session for families and couples, $160 for a 50-minute session for individuals. I charge the same rate, on a pro-rated basis, for phone calls or consultations over 15 minutes in length.

I maintain a 24-hour confidential answering service and check for messages daily during the week. I do not check my messages on weekends and holidays. When I am away for an extended period, I arrange for a colleague to cover my practice in case of emergencies.

I offer the option of phone or video sessions to supplement regular in-person sessions, and will discuss with you the benefits and limitations of this type of psychotherapy so that you may make an informed decision.

Please be aware that email and text communication may not be confidential, and I therefore ask you to limit text or email contact to brief scheduling changes.

It is your right to terminate therapy at any time. I encourage you to discuss this decision with me as it has been my experience that termination is a very important process.

I have read and understand the preceding information regarding clientsʼ rights and policies. I agree to the policies outlined.
Client or clientʼs responsible partyʼs signature, printed name and date: