Lori Hinze, MA, LPC, NCC

7222 Commerce Center Drive, Suite 132

Colorado Springs, CO 80919

Phone 719-314-7623

Fax 719-309-1295

Degree/Credentials

M.A. in Counseling from the University of North Dakota

Licensed Professional Counselor in the State of Colorado

Nationally Certified Counselor by the National Board of Certified Counselors

Clients Rights and Important Information:

a. You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy (if I can determine it), and my fee structure. Please ask if you would like this information.

b. You can seek a second opinion from another therapist or terminate therapy at any time.

c. In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the State Grievance Board. The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists, certified school psychologists, and unlicensed individuals who practice psychotherapy. The agency within the Department that has the responsibility specifically for licensed and unlicensed psychotherapist is the State Grievance Board, 1560 Broadway, Suite #1370,Denver, Colorado, 80202, 303-894-7766.

d. Generally speaking, the information provided by and to a client during therapy sessions is legally confidential if the therapist is licensed. If the information is legally confidential, the therapist cannot be forced to disclose the information without the client's consent. Information disclosed to me is privileged communication and cannot be disclosed in any court of competent jurisdiction in the State of Colorado without the consent of the person to whom the testimony soughtrelates. There are exceptions to the general rule of legal confidentiality. These exceptions are listed in the Colorado statutes.

You should be aware that legal confidentiality does not apply in a criminal or delinquency proceeding. There are other exceptions which include: 1) If I am required to report suspected child abuse or neglect to the appropriate law enforcement agency; 2) If I receive information from a client concerning a serious threat in imminent physical violence against a specific person, I must inform that person of the threat, and also notify law enforcement authorities; 3) I am required to initiate a mental health evaluation of a client who is dangerous to self or others,or who is gravely disabled, as a result of mental disorder; and 4) I am required to report any suspected threat to national security to federal officials.

e. In order to keep our relationship professional, please do not give me any gifts, however small. I have read the preceding information and understand my rights as a client. I also acknowledge that I have received a copy of this Disclosure Statement.

DISCLOSURE REGARDING DIVORCE AND CUSTODY LITIGATION

If you are involved in divorce or custody litigation, my role as a therapist is not to make recommendations to the court concerning custody or parenting issues.  By signing this Disclosure Statement, you agree not to subpoena me to court for testimony or for disclosure of treatment information in such litigation; and you agree not to request that I write any reports to the court or to your attorney, making recommendations concerning custody.  The court can appoint professionals, who have no prior relationship with family members, to conduct an investigation or evaluation and to make recommendations to the court concerning parental responsibilities or parenting time in the best interests of the family's children.

I have read the preceding information, and it has been presented to me verbally.  I understand the disclosures that have been made to me.  I also acknowledge that I have received a copy of this Disclosure Statement.