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Disclosure Statement

Allison Griffin, MA, LPC, NCC

Life Fulfillment Counseling 

Colorado License #0012570

13541 High Circle, Thornton, CO  80241

(303) 507-4853

Degrees and Credentials:

Bachelor of Science in Psychology - 1982

Colorado State University:  This was a 120 credit liberal arts degree with a major in psychology.  Half of the credits in the program were attributable to the psychology major.

Master of Arts in Counseling - 1997

University of Colorado at Denver: This was a 60 credit Master’s Degree CACREP program that required a semester of practicum counseling and a semester of internship counseling.  When the required coursework, practicum and internship were completed a comprehensive examination was required in order to be awarded the Masters in Counseling Degree.

National Board Certified Counselor (NBC) since 1998

National Board Certified Counselors must finish an accredited Master’s Degree program before being allowed to take the required examination to be certified.  The examination is comprehensive and passing it demonstrates a broad knowledge of the field of counseling and its theoretical applications and practices.

The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The Board of Registered Psychotherapist Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800. As to the regulatory requirements applicable to mental health professionals:

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 Counselor I (CAC I) must be a high school graduate, complete required training hours and 1,000 hours of supervised experience.
• Certified Addiction Counselor II (CAC II) must complete additional required training hours and 2,000 hours of supervised experience.
• Certified Addiction Counselor III (CAC III) must have a bachelor’s degree in behavioral health, complete additional required training hours and 2,000 hours of supervised experience.
• Licensed Addiction Counselor must have a clinical master’s degree and meet the CAC III requirements.
• Licensed Social Worker must hold a masters degree in social work.
• 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.
• Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a masters degree in their profession and have two years of post-masters supervision.
• A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision.

You are entitled to receive information from your therapist about the methods of therapy, the techniques used, the duration of your therapy (if known), and the fee structure. You can 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 board that licenses, registers, or certifies the licensee, registrant or certificate holder.

I regularly seek professional consultation and supervision with licensed psychologists Charleanea Arellano, Colorado license # 1902 at 12687 Locust Way, Thornton, CO  80602, 720-933-0318 and Betty Cannon, Colorado license #2029 at 1140 Lehigh St., Boulder, CO  80305, 303-494-0393.  During our sessions, identifying information is kept to a minimum.

Generally speaking, the information provided by and to the client during therapy sessions is legally confidential and cannot be released without the client’s 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. For example, mental health professionals are required to report suspected child or elder abuse to authorities.  They must also report when a client is at risk of harm to self or others and by court order.  You should be aware that, except in the case of information given to a licensed psychologist, legal confidentiality does not apply in criminal or delinquency proceedings.  This section does not apply to covered entities, their business associates, or health oversight agencies, as each is defined in the federal “Health Insurance Portability and Accountability Act of 1996,” as amended by the federal “Health Information Technology for Economic and Clinical Health Act,” and the respective implementing regulations.  I will identify exceptions to you as situations arise during therapy and will, whenever possible, share with you the intent to notify relatives or authorities.  In cases of threatened homicide or suicide, every effort will be made to resolve the issue before any other action is taken. If a legal exception arises during therapy, if feasible, you will be informed accordingly. The Mental Health Practice Act (CRS 12-43-101, et seq.) is available at: http://www.dora.state.co.us/mental-health/Statute.pdf.

I am not able to provide 24-hour care or after hours emergency services, therefore appropriate referrals are given to individuals in need of more intensive treatment.  Examples include, but are not limited to, individuals who are experiencing acute suicidal or homicidal thoughts, psychosis, or who require in-patient detoxification.  In the event of an emergency, contact your local mental health center (Community Reach Center, 303-853-3500), emergency room (St. Anthony’s North, 303-426-2151), or 911.

Services may be requested that are beyond the scope of my competencies, such as forensic assessments, child custody evaluations, or evaluations for disability accommodations.  Matters such as child custody, court testimony, and evaluations are beyond the scope of my mission.  In these cases referrals will be made to other agencies.

It is important to understand that there may be a potential for emotional strain, stress, and life changes as a result of therapy.  If you have any questions or concerns about this disclosure statement or would like additional information, please feel free to ask.

In couple and/or family therapy, I may disclose information shared individually in or out of a session, based upon my professional judgment.  All members of the couple or family have access to the file.  By signing this disclosure statement you acknowledge this and release information in this manner.

Fee Structure and Cancellation Policy:  Normal charge is $100.00 per session.  The usual session is 45 minutes.  I do not charge for brief phone calls, but I will charge for extended phone calls or case management contacts.  At times, unavoidable issues can come up for clients.  Appointments cancelled 24 hours in advance are not charged.  You may email or call and leave a voice mail message to cancel your appointment.  If you cancel your appointment because of an emergency, you will not be charged.  However non emergency cancellations without the required 24 hour notice will be charged.  It is important to know that insurance and EAP services cannot be billed for the missed session. 

I have read the preceding information, it has also been provided verbally, and I understand my rights as a client or as the client’s responsible party.

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Print Client’s name

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Client’s or Responsible Party’s Signature                                       Date

If signed by Responsible Party, please state relationship to client and authority to consent:

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