CHRIS BASSETT: Consent to Treatment

CHRISTINE BASSETT, MA, LMFT: Consent to treatment

Date(Required)

Client(s) Name(s)(Required)

First Last

Your Name(Required)

What is your relationship to the client?(Required)

CHRISTINE BASSETT, MA, LMFT

Christine Bassett, MA, LMFT • Colorado Licensed Marriage and Family Therapist (LMFT.698) • MA, Marriage and Family Therapy, 1999, George Fox University • BA, Interdisciplinary Child Development, Western WA University I received a Master's degree in Marriage & Family Therapy from George Fox University, in Oregon, and then became a Licensed Marriage & Family Therapist. Prior to that, I received a Bachelor's degree from Western Washington University in Interdisciplinary Child Development. I have worked as a therapist since 1999, working with couples, children, teens, women, men and groups, working in private practice and agency settings. I am the Executive Director at Lighthouse Christian Counseling, and I also supervise interns and staff who are working toward licensure.

Mandatory Disclosure Statement(Required)

The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of licensed and unlicensed counselors and marriage and family therapists. The agency with this responsibility is the State Grievance Board, 1560 Broadway, Suite 1350, Denver, CO, 80202, 303-894-7766. The regulatory requirements for mental health professionals provide that a Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a master's degree in their profession and have two years of post-master's supervision. A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision. A Licensed Social Worker must hold a master's degree in social work. A 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. A Certified Addiction Counselor I (CACI) must be a high school graduate, and complete required training hours and 1,000 hours of supervised experience. A CAC II must complete additional required training hours and 2,000 hours of supervised experience. A CAC III must have a bachelor's degree in behavioral health, and complete additional required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical master's degree and meet the CAC III requirements. A Registered Psychotherapist is registered/listed with the State Board of Registered Psychotherapists, but is not licensed or certified by the state, and no degree, testing, training or experience is required to obtain registration from the state. You are entitled to receive information from your therapist about the methods of therapy, the techniques used, fee structure and the duration of your therapy (if known). You may ask questions about your therapy at any time. You may discontinue therapy services at any time and for any reason. You are entitled to receive a second opinion from another therapist. If necessary, referrals to other counselors or marital and family therapists will be made available. In a professional therapeutic relationship sexual contact of any kind between a therapist and a client is never appropriate. If sexual intimacy between a client and therapist occurs, it should be reported to the State Grievance Board.

Teletherapy / E-Therapy(Required)

I hereby consent to engaging in tele-therapy and/or electronic therapy with Lighthouse Christian Counseling, as part of my mental health treatment. I understand that "tele-therapy" and "electronic therapy includes the practice of mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications such as the telephone, cellular phones, the internet, and various programs such as iChat, SKYPE, AIM, and Face-Time. I understand that if I am experiencing an emergency, seriously considering harming myself/suicide, or considering harming someone else that I should immediately go to the hospital or call 911 for help. I understand that I have the following rights with respect to tele-therapy and/or electronic therapy:

(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

(2) The laws that protect the confidentiality of my health information also apply to tele therapy and electronic therapy. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the tele-therapy and/or electronic therapy interaction to other entities shall not occur without my written consent.

(3) I understand that there are risks and consequences from tele-therapy and electronic therapy, including, but not limited to, the possibility, despite reasonable efforts on the part of my therapist, that: the transmission of my health information could be disrupted or distorted by technical failures; the transmission of my health information could be interrupted by unauthorized persons; and/or the electronic storage of my health information could be accessed by unauthorized persons. I also understand that the programs listed above have their own policies that might interfere with confidentiality and I am fully aware of the risks associated with working with these programs. In addition, I understand that tele-therapy and electronic therapy based services and care may not be as complete as face-to-face services, I also understand that if my therapist believes I would be better served by another form of psychological services (e.g, face-to-face services) i will be referred to a practitioner who can provide such services in my area.
(4) I understand that I have a right to access my health information and copies of records in accordance with state law.

I consent to Teletherapy/ E-Therapy. I have read and understand the information provided above, I have discussed it with my therapist, and any of my questions have been answered to my satisfaction. I understand that I do not have to participate in teletherapy and may choose to participate in in-person sessions instead. By checking this, you are eSigning this form.

In an Emergency

As is the case with most outpatient therapists, your counselor is not available at all times. Lighthouse encourages clients to develop additional support systems and to have access to other individuals and/or agencies in case of emergencies. Listed below are local emergency telephone numbers should you need them: Colorado Crisis Support: (970) 494-4200 Walk-in crisis center: 1217 Riverside Dr. Fort Collins, 80524 Crisis Assessment Center at Poudre Valley Hospital: (970) 495-7000 Call 911 or go to the nearest hospital emergency room

CHRISTINE BASSETT, MA, LMFT: Consent to treatment

CHRISTINE BASSETT, MA, LMFT

In an Emergency

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