Colorado College Counseling Center
Client Signature in 3 Places
State of Colorado Disclosure Statement
William R. Dove, Ph.D.
Licensed Clinical Psychologist (#1569)
Certified Substance Abuse Counselor, III (#18)
Doctorate from University of Denver
Carol A. Maynard, MSW, LCSW
Licensed Clinical Social Worker (#989775)
Pam Shipp, Ph.D.
Licensed Clinical Psychologist (#1415)
Doctorate from University of Denver
MA from University of Colorado, Colorado Springs
Erin Fry, D.O.-Psychiatrist
Alexis Wilbert PsyD
Licensed Clinical Psychologist
PsyD from University of Denver in Clinical Psychology
Ben Hindell LCSW, PsyD
Licensed Clinical Social Worker (09923207)
MSW from New York UniversityMSW from University of Denver
Betty Jo Smith, LPC/CAC III
Licensed Professional Counselor (#2589)
Certified Substance Abuse Counselor , Level III (#3528)
Irene Summers Temple Ph.D.
Licensed Psychologist (Il 071.008819)
Ph.D. In Counseling Psychology from Indiana University
All members of the Counseling Center staff utilize an eclectic therapeutic approach including elements of interpersonal, dynamic and
cognitive-behavioral therapies.
THE COLORADO DEPARTMENT OF REGULATORY AGENCIES
The Mental Health Occupations Grievance Board is the agency within the Department of Regulatory Agencies that has the responsibility of
regulating the practice of licensed and unlicensed psychotherapists. Any questions, concerns or complaints regarding the practice of mental health
services may be directed to: Mental Health Occupations Grievance Board,1560 Broadway St., Suite 1370, Denver, CO 80202.
CLIENT RIGHTS
You are entitled to receive information about the methods of therapy, the techniques used, the duration of therapy (if known) and the fee structure.
Information provided by you during therapy is legally confidential when working with a psychologist unless you sign an Authorization for Release of
Information. There are exceptions to this confidentiality in which professionals are required to take protective action. Such situations include when a
client presents a danger to self or others, or when child abuse or neglect is suspected. Limits of confidentiality can be discussed and will be identified
to you should any such situations arise during therapy.
Sexual intimacy is never appropriate within a professional relationship between a therapist and a client, and should be reported immediately to the
Grievance Board.
Your signature below signifies that you have been informed of your therapist’s degrees, credentials, and licenses and that you have read and
understand your rights as a client. If at any point you have concerns or questions about this, do not hesitate to ask.
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Client Signature
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Date
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Client Consent for services/evaluation:
I voluntarily apply for and consent to diagnostic and treatment services provided by the qualified mental health professionals of Colorado
College Counseling Center. I am aware that the mental health services are not based on an exact science and that the type(s) of treatment
received will depend primarily on my needs and abilities. I understand that, as such, I cannot be given any guarantees about the results of
treatment services. I understand that I may withdraw my consent at any time.
Client Signature__________________________________
Date _______________
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ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES
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PATIENT NAME (Please print)
Date of Birth
I acknowledge that I have received a copy of The Colorado College Counseling Center’s Notice of Privacy Practices
regarding the use and disclosure of my protected health information.
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Client Signature
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Date
CO UN SE LI N G CE NT ER AN D P S Y CH O LOGI C A L SE R VI CE S
1106 North Cascade Avenue, Colorado Springs, Colorado 80903
719-389-6093 tel 719-389-6064 fax
www.ColoradoCollege.edu