Client

Disclosure Statement

The Well Sessions: A Listening Company

Hello! As we begin our counseling relationship, I would like to provide you with this
disclosure of information as required by Colorado State Law and to ensure your safety and
understanding of the process.

1.INFORMATION
Lorissa Brunk, M.A., LPC
3260 Magnolia St Denver, CO 80207
(720) 675-9754
Licensure: LPC # 5176 (2009)
Degrees: Bachelor of Arts and Science, Wichita State University, 2003
Master of Arts in Counseling, Colorado Christian University, 2006,
My counseling style is experiential, mindfulness-based, and emotionally focused.
The course of therapy is dynamic and results are not guaranteed, however, many of
my clients report positive outcomes, greater joy, and ability to change and grow as
well as increased connection in their relationships. These benefits cannot be
accomplished without personal effort on behalf of the client. This effort includes
participation, honesty, openness and vulnerability. At times it may feel like things
are more painful or getting worse before they get better and at times the level of
honesty can be uncomfortable. I am open to feedback and will periodically ask for
your input on your progress and satisfaction with the process of therapy with me.

2. PROFESSIONAL EXPERIENCE
Honorarium Supervisor-University of Colorado Denver: Aug. 2010- 2012,
School Based Therapist-Community Reach Center: Aug. 2006-Aug. 2011
Private Practice- Denver, CO: Jan 2006- present

3. REGULATION OF PSYCHOTHERAPISTS
The Mental Health Licensing Section of the Division of Registrations regulates the
practice of licensed or registered persons in the field of psychotherapy. The
regulatory boards 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 bachelors degree in
behavioral health, complete additional required training hours and 2,000 hours of
supervised experience.
Licensed Addiction Counselor must have a clinical masters 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.

4. CLIENT RIGHTS AND IMPORTANT INFORMATION
a. You are entitled to receive information from me about my methods of therapy, the
techniques I use, and the duration of your therapy. Please ask if you would like to
receive this information. My fee is $65 for 45 minutes of counseling.
b. You can seek a second opinion from another therapist or terminate therapy at
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 Department of Regulatory Agencies.
d. Generally speaking, information provided by and to a client in a professional
relationship with a psychotherapist is legally confidential, and the therapist cannot
disclose the information without the clients consent. There are several exceptions
to confidentiality, which include: (1) I am required to report any suspected incident
of child abuse or neglect to law enforcement; (2) I am required to report any threat
of imminent physical harm by a client to law enforcement and to the person(s)
threatened; (3) I am required to initiate a mental health evaluation of a client who is
imminently dangerous to self or to others, or who is gravely disabled, as a result of a
mental disorder; (4) I am required to report any suspected threat to national
security to federal officials; and (5) I may be required by Court Order to disclose
treatment information, mental health treatment information concerning their minor
children, unless the court has restricted access to such information. If you request
treatment information from me, I may provide you with a treatment summary, in
compliance with Colorado law and HIPAA Standards.
e. Some clients achieve their goals in only a few counseling sessions; others may
require months or even years of counseling. As a client, you are in complete control
and may end our counseling relationship at any time, though I do ask that you
participate in a termination session. You also have the right to refuse or discuss
modification of any of my counseling techniques or suggestions that you believe
might be harmful. I assure you that my services will be rendered in a professional
manner consistent with accepted legal and ethical standards. If at any time for any
reason you are dissatisfied with our services, please let me know.

5. 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 recommendation to the court concerning parental
responsibilities or parenting time in the best interests of the familys children.

6. ELECTRONIC COMMUNICATION CONSENT
While engaging in internet and phone counseling, steps are taken on behalf to
provide as much confidentiality as possible, but I wish to make clients aware of the
potential hazards of unsecured communication. As such, I will take steps to verify
your authenticity at every session. I use encryption methods whenever possible.
While I will keep your communications private and will not share any information
without your permission, I am unable to control other circumstances in which
others may see the text of your message. If you are in any way concerned about the
contents of a message being read by someone other than myself, you might want to
consider alternative ways of contacting me. As part of this contract, if you choose to
communicate with me through text or e-mail or cell phone, you are agreeing not to
hold me responsible for any breach of confidentiality that may occur by someone
else accessing the information sent to or from me.

7. CANCELLATION: In the event that you will not be able to keep an appointment,
please notify me at least 2 hours in advance, whenever possible. If this 2-hour notice
is not respected, you will be billed $25 for your session.

8. REFERRALS: I recognize that not all conditions presented by clients are
appropriate for treatment with me. Specifically, phone counseling is not appropriate
for people who are homicidal, suicidal, self injuring, or requiring more care than one
session per week.
For this reason, you and/or I may believe that a referral is needed. In that case, I will
provide some alternatives including programs and/or people who may be available
to assist you. A verbal exploration of alternatives to counseling will also be made
available upon request. You will be responsible for contacting and evaluating those
referrals and/or alternatives.

9. EMERGENCIES: My services are not emergency based services. I am legally
required to refer, terminate or consult if I believe your needs are above my scope of
practice and availability. My services are available by appointment only. If you have
a true emergency, you will be expected to call 911 or go to your closest emergency
room. I am not available 24 hours a day.

Consent for Participation in Counseling Services

I understand that if I have any questions or would like additional information, I may
feel free to ask during the initial session and any time during psychotherapy
process.
I understand that confidentiality cannot be assured for electronic communication.
SIGNATURE: By signing below, you are indicating that you read and understood this
statement (4 pages) or that any questions you had about this statement been
answered to your satisfaction and that you were furnished a copy of this statement
if requested.
___________________________________________
Print Client Name



___________________________________________
Address





____________________________________________
Client or (representative) signature

____________________________________________
Emergency Contact

____________________________
Date

____________________________
Phone

_____________________________
(Relationship to client)

______________________________
Emergency Phone #