Client Name: ____________________
Today’s Date______________
Initial_____
Ewa Ostoja-Starzewska, Ph.D., Licensed Psychologist , License: 2462
2014 Caribou Drive, Suite 150, Fort Collins, CO 80525 970-214-557, Fax: 970-226-5574
Consent to Assessment and Treatment
____________________________ ______________________ _____________________
This form is being completed by (name of client and/or parents/for minors)
_______________________________
Client’s Date of Birth
________________________________________
Date this document is being reviewed and signed
__________________________________________________________________________
(For minors) Parent or Guardian’s Names
Please read the following information. This agreement between you and the
provider is a legally binding document. It contains important information about
your treatment. Please review each section and initial or sign as appropriate.
Thank you!
BACKGROUND INFORMATION ABOUT THE TREATING PROFESSIONAL
Welcome to Dr. Ostoja’s practice. I am a Licensed Clinical Psychologist. I received my
Doctorate in Clinical Psychology and in Developmental Psychology from the University of
Minnesota in 1996. I have been treating clients for over 15 years. I treat adults, adolescents,
children, and families.
As a Psychologist, and a member of the American Psychological Association (APA), I
will make every effort to provide you/your family with the highest quality assessment and
treatment available to date. Nevertheless, I encourage you to discuss with me any research and
information you may obtain yourself regarding your condition or available treatments.
The following pages explain various aspects of your treatment. If you are receiving this
document by email, please print it or print the signature pages and bring them signed to your first
appointment. If you prefer, Dr. Ostoja can provide you with a printed copy, which you can sign
at Dr. Ostoja’s office. Please retain a copy for your records, and for future reference. Some of
the wording in the following pages is required by the Psychology Boards.
If you are a parent, and your child is 15 years of age or older, your child will have to cosign this agreement (this will be done at the end of the first session). If your child is younger than
15 years old, please remind Dr. Ostoja when your child turns 15 years old that your teen will
need to sign this agreement.
Please initial each page at the top right corner to indicate that you have read the page.
Each section of this agreement between you and the provider (Dr. Ostoja-Starzewska) requires
your signature, with today’s date.
Ewa Ostoja-Starzewska, Ph.D., Licensed Psychologist, License: 2462
2014 Caribou Drive, Suite 150, Fort Collins, CO 80525 970-214-557, Fax: 970-226-5574
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Client Name: ____________________
Today’s Date______________
Initial_____
LEGALLY MANDATED DISCLOSURE OF INFORMATION
The following laws and rules have been developed to protect the welfare of patients and
families. Although the majority of providers are very conscientious about acting in the best
interest of their patients, some commit well-meaning but harmful errors. The laws outlined
below are designed to remind patients and providers that the therapeutic relationship is
unique and delicate, and that it is best to respect the therapeutic boundaries and to follow
guidelines developed by professional organizations.
I am required by law to let you know that the practice of Psychology in Colorado is regulated by
the Department of Regulatory Agencies. If you have any questions or concerns about my
practice or the practice of any other psychologist, you may contact:
Department of Regulatory Agencies, Mental Health Section
1560 Broadway, Room 1340, Denver, CO 80202
In order to provide you and your family with the highest quality of care, I participate in
professional organizations. I am a member of the American Psychological Association (APA). I
make every effort to adhere to the high professional standards of the APA. Concerns and
complaints regarding any Psychologist may also be filed with the APA. In addition, I am a
member of the International Obsessive Compulsive Disorders Foundation (IOCDF), and of the
Colorado Psychological Association (CPA). Because I want to provide you with the best possible
care, I regularly complete continuing education courses. Recent courses I have completed
include: Treatment of Social Anxiety, Treatment of Obsessive Compulsive Disorder, Treatment
of Bipolar Disorder, Ethical and Legal Issues for Psychologists, Diagnosis and Treatment of
Sleep Disorders, and others.
By law, I also need to let you know that as a Psychologist, I provide services in accordance with
the following guidelines:

As a client, you are entitled to receive information about the methods of therapy, the
techniques used, the duration of therapy, and, if known, the fee structure.

As a client, you may seek a second opinion from another therapist or may terminate therapy
at any time. However, it is usually advisable to discuss concerns with the treating
Psychologist (me) as soon as problems arise, so that a mutually acceptable solution can be
reached. It is also usually not advisable to see more than one provider at a time (for example,
seeing two Psychologists for individual therapy simultaneously), unless discussed with both
providers ahead of time. On the other hand, it is common for clients to see an individual
therapist, a psychiatrist, and a family therapist, as long as these providers can discuss with
each other the care of the client (with appropriate consent from the client).

Although this point seems obvious, by law I am required to let you know that in a
professional relationship, sexual intimacy is never appropriate and is illegal. It should be
reported to a grievance board. Please know that if you tell me that another provider, either
medical or mental health, has violated this rule, I will be obliged to report it to that person’s
professional grievance board.
Ewa Ostoja-Starzewska, Ph.D., Licensed Psychologist, License: 2462
2014 Caribou Drive, Suite 150, Fort Collins, CO 80525 970-214-557, Fax: 970-226-5574
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Client Name: ____________________

Today’s Date______________
Initial_____
In general, the therapeutic relationship is unique and separate from friendship and
acquaintance relationships. For example, in order to protect your privacy and confidentiality,
I will not acknowledge you or your family in public (for example, I will not say hello to you
unless you initiate contact first). I will not be offended or hurt if you choose not to
acknowledge me, as this is an explicit agreement of our relationship. Many clients prefer to
avoid having to explain to their friends that I am their Psychologist. However, please feel
free to approach me and say hello if you would like.
Additional information about the therapeutic relationship:
 DUAL RELATIONSHIPS: The unique nature of the Psychologist-client relationship means
that I will generally avoid socializing with you or with my other clients outside of our
therapy sessions (this is known as dual-relationships). In our mid-sized town there are
occasional situations where Psychologists and clients come in contact with each other outside
of therapy sessions. Whenever I become aware of such a potential situation, I will attempt to
discuss this situation with you so we can agree on a mutually acceptable solution. This also
applies to past clients, though once therapy is terminated for at least 2 years, the potential for
harm to the client is significantly diminished. Please feel free to discuss any concerns you
may have regarding such situations as soon as they arise.


THERAPIST’S SELF-DISCLOSURE: Many therapists and Psychologists limit the amount
of their own personal disclosure in sessions. This is done in order to maintain the focus of
therapy on the client’s needs, and is not intended to be stand-offish or distant. The
therapeutic relationship is unique in its focus on the needs of the client, without any
expectation of reciprocity in caretaking for the therapist. On the other hand, some selfdisclosure by therapists has been found to be helpful to clients. Therefore, like many
Psychologists and therapists, I sometimes use personal examples or stories to illustrate
coping strategies or handling of problems. The aim of such disclosures is not to talk about
myself, and not to suggest that I am better at handling problems than the client (that “I have it
all figured out.”). All therapists are human and we all struggle with ordinary life challenges.
The goal of such self-disclosures is to model tolerance of not being perfect, to demonstrate
that it is beneficial to show vulnerability, and to provide another avenue (often humorous) for
discussing potentially helpful coping strategies. However, therapist’s self-disclosure has to be
limited and the focus must remain on the client. This is an example of a therapeutic boundary.
Sometimes clients ask me personal questions that are best not answered. I ask that you not be
offended if I refuse to answer a particular personal question. This will occur if I do not
believe that answering such a question would be in the best interest of the client (you or your
family). If this feels awkward, it would be beneficial for us talk about the issue further and
explore it for therapeutic benefit.
Confidentiality and Exceptions
CONSULTATIONS WITH OTHER PROVIDERS: My actions as a Psychologist are guided
by respect for each client. I will not share your stories with others without your expressed
consent. However, please be aware, that from time to time, I may seek professional
consultation with colleagues, experts in the field, or my professional organizations. I will not
reveal your name or identity in such consultations, but I may discuss the particulars of your
situation. The aim of such consultations is to provide better care, and to become a better
provider. The colleagues I will consult with are also trained professionals and will not
Ewa Ostoja-Starzewska, Ph.D., Licensed Psychologist, License: 2462
2014 Caribou Drive, Suite 150, Fort Collins, CO 80525 970-214-557, Fax: 970-226-5574
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Client Name: ____________________
Today’s Date______________
Initial_____
disclose any clinical information to others. Any consultations which require that your identity
to be revealed will only be done with your signed consent.

EXCEPTIONS TO CONFIDENTIALITY: The information provided by the client during
therapy is legally confidential, except in certain legal exceptions. Legally mandated
exceptions to confidentiality include the following:
o CHILD ABUSE: The Department of Human Services (DHS) and/or police must
be notified if there is suspicion of abuse/neglect of a child under 18 years old, an
elderly person, or a vulnerable person (this could be someone outside of your
family). I will have no choice but to contact the Department of Human Services if
I become aware of such potential abuse. This applies to yourself and your family,
as well as other persons you may tell me about.
o HOMICIDAL IDEATION OR THREATS/DUTY TO WARN POTENTIAL
VICTIMS: Protective actions will be taken if a client threatens serious bodily
harm to another person. Protective actions may include notifying the potential
victim, notifying the police, and/or seeking appropriate hospitalization. For
example, if one of my clients discloses a desire to burn down a school, hurt a
teacher or a peer; or even if I find out that a parent threatens to harm his/her
daughter’s boyfriend, I will have to contact the person who is threatened and the
police. Please know that I will also break your confidentiality if you disclose that
someone you know may be dangerous to others.
o SUICIDAL IDEATION: Protective actions will be taken if a client threatens to
harm himself/herself. Protective actions may include seeking hospitalization
and/or contacting family members or others who can help protect the client. For
example, if an adolescent discloses suicidal ideation, or if his/her parent or teacher
reports any suicidal threats, I will need to send the adolescent to the Emergency
Room. I will usually try to problem solve with the client and the family, and
encourage the parents to transport the adolescent to the Emergency Room, but if
the adolescent or the family refuse, I may have to call 911. My primary obligation
as a professional is to protect the client from imminent harm. Although my
objective is to keep my clients out of the hospital, there are times when a person
must be under close observation for a few days to allow for rapid medication
adjustments, problem solving, and time to permit the immediate impulses for selfharm to pass. Please know that I will also break your confidentiality if you report
that someone you know is at serious suicidal risk.
o Other exceptions to confidentiality are outlined in the Privacy Notice under the
Health Information Portability and Accountability Act (HIPAA). I will be asking
you to review and sign a HIPAA Notice Form, where such other exceptions are
discussed in detail. Briefly, these include responding to court orders for release of
records, complying with police orders, and complying with investigations by
government agencies and professional licensing bodies.
Ewa Ostoja-Starzewska, Ph.D., Licensed Psychologist, License: 2462
2014 Caribou Drive, Suite 150, Fort Collins, CO 80525 970-214-557, Fax: 970-226-5574
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Client Name: ____________________
Today’s Date______________
Initial_____

CONFIDENTIALITY OF CONVERSATIONS BETWEEN Dr. Ostoja AND CHILDREN
AND TEENS. In conducting therapy with children, adolescents, and families, issues of
confidentiality arise with significant frequency. I will attempt to clarify these issues from the
outset and throughout therapy. In general, whenever I function as an individual therapist for a
child or an adolescent, I will be requesting significant amounts of privacy from parental
knowledge. Children and adolescents are more likely to discuss issues openly and to benefit
from therapy when they know that their parents will not hear every word of their individual
sessions. As explained above, exceptions to this include issues of safety to the child, or to the
family and others (e.g., peers, school). I will also have to break a child’s or an adolescent’s
confidentiality if there are concerns about child abuse or neglect. Beyond these extreme
situations, I will walk a fine line between telling parents about potential safety concerns (e.g.,
teen sneaking out, spending time with friends that parents may disapprove of), and
maintaining the teen’s confidentiality. At the same time, please keep in mind that children
and adolescents often fail to report many important aspects of their lives to their therapist.
Just because your teen is coming to see me and appears to have a positive relationship with
me, it does not mean that I know everything about their lives. Sometimes teen hide
information from all adults. Teens and children are also still immature and may not realize
that it would be helpful for me to know about an important fact or event. They may also
assume that I already know. As a parent, you are responsible for attending sessions regularly,
or for communicating through other means such as voicemail messages (at additional cost if
this requires significant amounts of out-of-session time), and for keeping Dr. Ostoja updated
regarding important events, stressors, and other important issues in the child’s/adolescent’s
life. In particular, it is a parent’s responsibility to inform Dr. Ostoja regarding medication
changes, hospitalizations, physical altercations, suicidal or homicidal statements, child abuse,
drug abuse, and significant family or peer conflict affecting your teen.

CONFIDENTIALITY IN GROUP THERAPY: If you participate in group therapy, it is
necessary for you to agree to protect and respect the privacy of other group members. You
need to agree not to share personal information, including the names of other group members,
with people outside the group. You may expect other group members to show the same
respect for your confidentiality.

EFFECTIVENESS OF TREATMENT CANNOT BE GUARANTEED: Please note that I am
required to inform you that I cannot guarantee that mental health treatment will effectively
fix a client’s problems. I base my assessments and treatment on up-to-date research that is
endorsed by the American Psychological Association. If in doubt, my guiding principle is to
“do no harm.” I am cautious and patient in my approach. I do not use experimental
treatments or deception. I will always try to explain any specific interventions ahead of time
and seek your/your child’s or family’s consent. Nevertheless, therapy involves increases in
self-knowledge and significant amounts of change. This can at times cause discomfort.
Please communicate to me as soon as possible any concerns you may have regarding your
treatment. Please feel free to check in with Dr. Ostoja regularly regarding your assumptions
and expectations of treatment. While Dr. Ostoja exerts every effort to provide the most
effective treatment available, Dr. Ostoja can only be of as much help as is permitted by the
client’s readiness, openness to recommendations, compliance with homework, and the
overall complexity of the presenting problem. For some patients, not getting worse is a
therapeutic success. For others, de-compensations in symptoms may occur as a result of the
Ewa Ostoja-Starzewska, Ph.D., Licensed Psychologist, License: 2462
2014 Caribou Drive, Suite 150, Fort Collins, CO 80525 970-214-557, Fax: 970-226-5574
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Client Name: ____________________
Today’s Date______________
Initial_____
natural course of their underlying psychiatric condition, stressful events, or other factors.
Please discuss your expectations, hopes and concerns directly with Dr. Ostoja in a timely
manner.

IF YOU ARE SEEKING A PSYCHOLOGICAL EVALUATION OR TREATMENT FOR
COURT OR LEGAL PURPOSES, you are strongly encouraged to seek another provider. Dr.
Ostoja does not specialize in legal matters. There are providers who are trained and
experienced in providing assessment and therapy for court purposes. They will represent you
much more effectively in court. Dr. Ostoja realizes that there are some unforeseen
circumstances, such as divorce proceedings or other legal matters, which occur months after
therapy is initiated. In such circumstances, it is natural for clients to request summaries,
letters, or recommendations. Please know that I will exert every effort to refuse such requests.
The integrity of the therapeutic process rests on my ability to create a safe and confidential
environment for my clients, including children and adolescents. However helpful it may
seem for me to issue an opinion, it is almost never beneficial for me to participate in the legal
process involving my clients. I will always be viewed as a biased informant. The information
I obtain in the course of therapy does not meet the stringent standards required for
evaluations conducted for legal purposes. If you can reasonably anticipate that you will
require such letters or assessments, I ask that you disclose this at the outset of your or your
child’s therapy, and I strongly encourage you to seek another provider. It is best to seek
expert opinion from an independent assessor who agrees at the outset of an evaluation to
serve as an expert witness.

Please know that I will have no choice but release records if I receive a court order to do so. I
will have to copy your or your child’s entire chart, including records of confidential
therapeutic conversations recorded as part of your or your child’s therapy. Such records
usually contain significant amount of detail regarding your history and your presenting
problem, as I am required to keep adequate records to document appropriate treatment
interventions. Therefore, it is best to consider carefully any decision to introduce your mental
health history as a factor in legal proceedings. Many lawyers do not realize the negative
implications of introducing mental health issues to legal proceedings. Please discuss this
openly with your lawyer. Please let them know that I will try to discourage you from
requesting your records for legal purposes. Also, please know that there will be fees
associated with the time and resources required to produce such copies of records (see below
for details).

If Dr. Ostoja receives a court order to release records or appear in court, or if she is court
ordered to render any kind of an opinion, Dr. Ostoja will charge a fee of $200.00/hour. Such
court orders will result in a minimum of 3-5 hours to review patient records per each year of
treatment (more for complicated cases). An estimated fee will be collected prior to the
services provided. None of such fees will be covered by your insurance. The above charges
will apply also to time spent preparing letters, time speaking with other therapists or
psychiatrists or doctors, time spent traveling to court, time spent waiting in court, phone calls
with attorneys or other representatives and professionals, as required by the legal proceedings.

Please note that insurance will not cover services related to services, which are legal in nature,
such as divorce proceedings, custody proceedings, auto accidents, legal proceedings against
Ewa Ostoja-Starzewska, Ph.D., Licensed Psychologist, License: 2462
2014 Caribou Drive, Suite 150, Fort Collins, CO 80525 970-214-557, Fax: 970-226-5574
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Client Name: ____________________



Today’s Date______________
Initial_____
an employer or an educational institution and others. If you are involved or expect to be
involved in such proceedings, please inform Dr. Ostoja immediately and obtain an
appropriate referral.
NO LETTERS OF REFERENCE ARE PROVIDED: Please note that Dr. Ostoja does not
provide letters of reference for jobs or school applications. I generally advise patients against
using therapists for this purpose, as it may not be well received or understood by potential
employers.
Dr. Ostoja does not provide letters or opinions in child custody cases, as it is outside of Dr.
Ostoja’s area of competence. Dr. Ostoja may choose to provide letters (at an additional fee),
if appropriate and warranted by regular attendance and progress in therapy, documenting Dr.
Ostoja’s professional opinion regarding, for example, a patients’ fitness to return to work
(such letters are provided only for regular patients who have attended at least 25 sessions
prior to the date of the request), requests a for brief leave of absence (regular patients only),
and 504 accommodations for school. Please note that Dr. Ostoja does not have a final
decision making power in such applications, and can only render her professional opinion,
which may or may not be accepted by relevant decision makers.
RELEASE OF RECORDS TO SCHOOLS, OTHER PROVIDERS, and other parties: Dr.
Ostoja does not release complete records of treatment to other parties, even with patient or
parent consent, unless mandated by the courts. It is generally not in a patient’s or
child’s/adolescent’s best interest to have the complete content of their therapy records (which
includes documentation of many private conversations, feelings, anxieties, thoughts and
behaviors) released to third parties. For professional consultations for the purpose of
coordinating care, Dr. Ostoja will encourage you to allow her to communicate verbally brief
summaries to other therapists or physicians (15 minutes per month or 30 minutes per 6
months), with appropriate consent from you/your child. Written summaries or longer
communications may be provided at additional fees, as listed in the fee section.
I have read and understood the above information. I consent voluntarily to the above terms and
conditions of service. I have received a copy of this form for my records.
_____________________________ Date of Birth__________________ Age _________
Client Name (Print)
_____________________________
Client Signature
___________________________
Date
____________________________
Parent’s Name (Print) (for minors)
__________________________
Parent Signature
__________________
Date
____________________________
Parent’s Name (Print) (for minors)
__________________________
Parent Signature
__________________
Date
_____________________________
Signature of Witness
____________________________
Date
Ewa Ostoja-Starzewska, Ph.D., Licensed Psychologist, License: 2462
2014 Caribou Drive, Suite 150, Fort Collins, CO 80525 970-214-557, Fax: 970-226-5574
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