Denver Family Solutions
Jessica L Ragsdale, LMFT
6343 W 120 Th
Broomfield, Co 80020 www.DenerFamilySolutions.com
Client Information:
Name:
Street Address:
City:
Date of Birth:
Home#:
Work #:
Email Address:
ZIP:
Date:
SS#
DL#
Age:
Cell#:
What is the best method to contact you?
Do I have permission to leave messages on home phone (Y/N), Work (Y/N), Cell (Y/N), and Email (Y/N)?
Please mark any symptoms that have occurred in the past 6 months
Anxiety Depression Suicidal Thinking Obsessive thoughts
Weight gain
Mania
Weight Loss
Drug use
Anger
Violence
Irritability
Abuse
Impulsive
Panic
Sleep Disturbance Memory
Impairment
Risky Behavior Pain
Performance impairment
Withdrawal
Have you seen a therapist before? When and for what issues -
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Please tell me about your social outlets, support, and whom you share your problems:
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Have you ever been diagnosed with a mental illness? _________________________________
Are you currently taking any psychotropic drugs? Who is the prescribing doctor?
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Denver Family Solutions
Jessica L Ragsdale, LMFT
6343 W 120 Th
Broomfield, Co 80020 www.DenerFamilySolutions.com
Have you ever had suicidal thinking or behaviors?
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Have you ever been hospitalized for a mental health concerns or a danger to self or others?
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Has anyone in your family (or close friend) ever completed a suicide?
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Is there a history of abuse in your past?
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Is there or has there been violence in your home?
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Please tell me who is currently living in your home and if there are children please list their ages:
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Please tell me about your history and current use with alcohol and drugs. Have you ever been to rehabilitation for these substances or used another program to help with an addiction? Please describe your current use:
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Are you or have you ever been a victim of a hate crime?
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Have you ever used violence against someone or been charged with a violent crime
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Denver Family Solutions
Jessica L Ragsdale, LMFT
6343 W 120 Th
Broomfield, Co 80020 www.DenerFamilySolutions.com
Could you describe any trauma that you have experienced:
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Are you currently under the care of a medical doctor and for what reasons?
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Please tell me about any major surgeries or illnesses that you have had:
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Please list all prescriptions and the name of the prescribing doctor:
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Why are you seeking therapy at this time and what are your hopes for the following sessions:___________________________________________________________________________
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How did you find my services: (please circle any that apply)
Referral Google search Psychology Today
Therapy Tribe Insurance Referral Other:
Client Signature
Therapist Signature
Date
Date

Denver Family Solutions
Jessica L Ragsdale, LMFT
6343 W 120 Th
Broomfield, Co 80020 www.DenerFamilySolutions.com
The following information sheet is to provide you with mandated information by the Colorado
Department Of Regulatory Agencies. This information is meant to educate and inform you so that you can make the best decisions possible for yourself and family. The form will also provide detailed information on my education and business practice.
Jessica Ragsdale is a Marriage and Family Therapist. She holds a state licensure in both
Colorado and California at this time. To obtain this license a Masters Program was completed along with a three year internship focusing on family, couples, and children. She also passed the require boards through testing, which in turn earned her the MFT license.
The state board with authority over this license is the Mental Health Licensing Section of the
Division of Registrations. The Board of Marriage and Family Therapy Examiners can be reached at 1560 Broadway. Suite 1350 Denver, CO, 80202. 303-894-7800
State Requirements for all mental health professionals:
Licensed clinical social worker, marriage and family therapist, and Licensed Professional Counselors- all must hold a masters degree and two years of post masters supervision. A licensed social worker must have a masters in Social work.
Psychologist- Doctorate Degree in psychology and one year post-doctoral supervision.
A psychologist candidate, marriage and family therapist candidate, and an Licensed Practical Counselor candidate must have completed the necessary licensing degree and are working on completing supervision.
A certified Addiction counselor (CAC)-is a high school graduate and has completed necessary training. CACI have completed 1000 hours of supervision while CAC II have completed 2000 hours of supervision. A CAC III has a bachelor’s degree in behavioral health, completed additional training, and complete 2000 hours of supervisory experience. A licensed Addiction Counselor - has a Masters degree and meet the requirements of a CAC III.
A Registers Psychotherapist -registered with the State Board of Registered Psychotherapist, is not licensed, certified, and no degree or training is required
(Information provided by www.DORA.gov
)
In all of the above professions, sexual intimacy with clients is never appropriate and should be reported immediately to the following agency:
Department of Regulatory Agencies, Division of Registration, Mental Health Boards, 1560
Broadway, Suite 1350, Denver, CO 80202

Denver Family Solutions
Jessica L Ragsdale, LMFT
6343 W 120 Th
Broomfield, Co 80020 www.DenerFamilySolutions.com
Client Rights:
The client has the right to receive information about therapist methods of therapy, fees, and duration of therapy (if known).
The client has the right to terminate therapy at any time
The client has the right to seek a second opinion
The client has the right to a confidential relationship with the therapist
Both by law and my professional ethics, client/therapist communications are confidential in nature. However, there are legal mandates that also define when confidences are required to be broken. The follow conditions bring the exceptions to confidentiality:
1.
The client authorizes the release of information
2.
The client is a danger to him or her self
3.
The client is a danger to others
4.
Clients’ records are ordered by the court
5.
In the case of suspected child or elder abuse
6.
Unpaid fees may be reported to collection agencies
By signing below you state that this document has been discussed with your therapist verbally and that you understand, fully, the statements listed above. Your signature also states that you, the client, have read the information and understand your rights as a client. By signing this form you are consenting to treatment with Jessica Ragsdale, MFT or are giving permission to engage in treatment with your child.
Date_______________________________________________________________
Client Signature___________________________________________________
Therapist Signature_________________________________________________

Denver Family Solutions
Jessica L Ragsdale, LMFT
6343 W 120 Th
Broomfield, Co 80020 www.DenerFamilySolutions.com
Office Policies and Financial Agreement
Financial Agreements:
My fee is $120.00 per theraputic hour (50 minutes). This fee may also be pro-rated for phone calls, extended sessions, or report writing. Fees are paid at the end of session.
Should professional fees be changed the client will be informed in writing of the change.
Unpaid balences will be reported to a collection agency after 90 days past due.
Should the client be using insurance as the primary payer source, the client understands that the therapist is required to be in contact with the insurance where personal and protected health information will be exchanged. Please review privacy policy and discuss concerns with your therapist.
Initials _________ Change is customary Fee_________________
Cancellations:
Your therapy hour has been reserved for you. Therefore, appointments must be broken
24 hours before the time agreed upon. Should you cancel before this time there will be no fee added to your account. However, cancellations received within this 24 hour period will be charged a $50.00 fee. “No-shows” will be charged a full session fee.
Initials __________
Email Clients understand that this therapist can not guarantee the privacy of information sent over the internet via email. Should the client engage in email communications or indicate the email communication is allowable the client also agreed to the risk of these communication.
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Emergency and vacation policies
I will make my self available to you if possible during times of emergency. This may be in the form of a phone call, or the scheduling of bi-weekly appointments. However, I do not have an emergency number and therefore can not guarantee that you will be able to reach me. Please utilize local crisis lines during these times or by calling 911. I will inform you of any times services I will not be available (vacation, illness etc.), and provide you with alternate options for service. Initials__________

Denver Family Solutions
Jessica L Ragsdale, LMFT
6343 W 120 Th
Broomfield, Co 80020 www.DenerFamilySolutions.com
Child Care
I am the primary care provider for my child. Clients understand that I may have to cancel due to illnesses of the child, general lack of child care, or in emergencies.
Therapist will also have to make her self availbel to be reached even in session. I will also allow this for clients with children. Clients are also asked not to attend session while ill themselves. These type of cancellations due require a 24 hour notice with the exception of extreme cases. Initials__________
Practice Closure
Should the therapist close the practice for any reason clients will be notified with in a 2 week time period. All clients will be offered three alternative treatment providers at this time. Clients also understand that durring treatment should the therapist feel the client would be better served with another clinical, referals would be given at that time.
Initials_______
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Clients Signature and Date

Denver Family Solutions
Jessica L Ragsdale, LMFT
6343 W 120 Th
Broomfield, Co 80020 www.DenerFamilySolutions.com
AUTHORIZATION FOR A CHILD TO RECEIVE COUNSELING SERVICES
Childs Name:
Date of Birth:
Primary Address:
I GIVE MY PERMISSION FOR MY CHILD__________________________________, TO
PARTICIPATE IN COUNSLEING WITH JESSICA L.RAGSDALE, MFT.
PARENTS NAMES: ________________________________________
ADDRESS ________________________________________
________________________________________
PHONE NUMBER: ________________________________________
Please sign below in the presence of the counselor providing services.
DATE SIGNATURE DATE WITNESS
What are the reasons you are seeking support at this time?

Denver Family Solutions
Jessica L Ragsdale, LMFT
6343 W 120 Th
Broomfield, Co 80020 www.DenerFamilySolutions.com
1.
PURPOSE: This Notice describes how medical and mental health information about you may be used and disclosed and how you can get access to this information. Throughout the process of therapy, information with be gathered. Ordinary this information will be keep confidential with the exceptions that are listed below. This policy applies to all Denver Family Solutions employees, management, contractors, student interns, and volunteers. This policy describes the objectives and policies regarding maintaining the privacy of patient information.
2.
USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION a.
General uses of Information that do not need consumers Consent include the following:
1) Treatment: Refers to the coordination of managed health care (and mental health care). This may be due to clinical consult, a common practice, to assure best practices are appropriate methods are being used to assist the client.
2) Payment: This is the process of obtaining reimbursement from health care plans. This information provided to insurers may include diagnosis, information that identifies you or the policy holder, dates of service, and information surrounding your treatment and condition. b.
Contacting the Consumer: Denver Family Solutions may contact you for appointment reminders or to communicate around treatment outside of the therapy session. Please note that should this information be shared over e-mail, Denver Family Solutions cannot guarantee that the information will remain confidential. c.
Family Members: Health information cannot be provided to family members without consent. However, in situations where client’s bring family members to session it is inferred that the consumer does not object to information being shared. d.
27-10: Information for those who are being treated involuntary can legally be shared with other entities for the coronation of care. e.
Law Requirements; Refers to the mandatory disclosure of information due to state/federal requirements. This includes the following situations;
1) The therapist is Court Ordered to Release Information
2) There is a legal Duty to Warn
3) The client is gravely disabled or a danger to self or others
4) When a Coroner is investigating the clients death
3.
Emergencies : In life threatening situations DFS will disclose information to avoid harm or death.
4.
INDIVIDUAL RIGHTS a.
Right to access/copy PHI: You may ask for a copy of the PNI that DFS has on file b.
Right to amend PHI: You have the right to ask for incorrect information to be amended. However, should DFS find the record to be accurate DFS is not required to change the record. c.
Right to a copy of this notice. d.
The client has the right to release their personal information through the use of a signed authorization e.
Right to confidential communications: Clients have the right to request how communications happen between client and DFS. f.
Right to an accounting of disclosures: Clients can request an accounting of all disclosures made to the record g.
Right to file a complaint: If you believe DFS has violated your rights, clients can contact The United States Secretary of Health and
Human Services. (The Office of Civil Rights, USDHHS, 200 Independence Ave, SW, Room 515F, HHH Blg, Washington DC 20201)
I have received/reviewed Denver Family Solutions Privacy Policy. Please Sign and Date Below:
________________________________________________ __________________________________________

Denver Family Solutions
Jessica L Ragsdale, LMFT
6343 W 120 Th
Broomfield, Co 80020 www.DenerFamilySolutions.com