DISCLOSURE STATEMENT AND FEE AGREEMENT
1. INFORMATION:
Kelly Stuerke
305 W South 1st Street
Johnstown, CO 80536
970-405-6564
2. CREDENTIALS:
Degrees:
Master of Social Work
B.A. in Psychology.
Professional Experience: I received a Master of Social Work degree from Colorado State University in 2012, as well as a Bachelor of Arts in
Psychology from the University of Northern Colorado in 2006. My background includes working with high-risk youth, couples, families, and
survivors of trauma. I specialize in the treatment of depression, anxiety, post traumatic stress disorder, body image issues, self harming behaviors,
sexual assault survivors, domestic violence survivors, and substance abuse. I utilize an eclectic combination of CBT (Cognitive Behavioral Therapy)
and DBT (Dialectical Behavioral Therapy), and also offer EMDR (Eye Movement Desensitization & Reprocessing). I am currently working towards
obtaining my Licensure in Clinical Social Work. I use a solution focused, strength based approach to build empowerment. In order to provide you
with the best quality of care, I consult with other practitioners on an occasional basis, while continuing to protect your confidentiality.
3. REGULATION OF PSYCHOTHERAPISTS
The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of
Registrations. Licensed Marriage and Family Therapists are regulated by the Board of Marriage and Family Therapist Examiners. A LMFT must
hold a masters degree in their profession and have two years of post-masters supervision. Licensed Social Workers and Licensed Clinical Social
Workers are regulated by the Board of Social Work Examiners. A LSW must hold a masters degree in their profession. A LCSW must hold a masters
degree in their profession and have two years of post-masters supervision. Licensed Professional Counselors are regulated by the Board of
Professional Counselor Examiners. A LPC must hold a masters degree in their profession and have two years of post-masters supervision. Licensed
Psychologists are regulated by the Board of Psychologist Examiners. A LP must hold a doctorate degree in psychology and have one year of postdoctoral supervision. Unlicensed psychotherapists that are candidates for licensure as Psychologists, Marriage and Family Therapists, Clinical Social
Workers, and Professional Counselors must hold the necessary licensing degree and be in the process of completing the required supervision for
licensure. Unlicensed psychotherapists who practice in a community mental health centers are not required to be registered in the State’s database.
Certified Addiction Counselors are regulated by the Board of Certified Addiction Counselors. A Certified Addiction Counselor I (CAC I) 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.
All boards described above can be reached at 1560 Broadway, Suite 1350, Denver, Co 80202. (303)894-7800. It is important to address each board
directly based off of your therapist’s licensure and/or certification.
4. FEE INFORMATION

You are responsible for any co-payments or deductibles as required by your insurance company. If you are self- pay, my fees are decided
by a sliding scale are as follows:
-50 minute sessions $70-$100 per hour depending on income
-Group sessions $ 30
-Court Appearances $200 per hour

Payment is due in the form of cash, check, or credit/debit card at the time services are rendered.

If payment is not received within 45 days of the service(s) rendered, the bill for such services may be turned over to a collection agency. If
your outstanding balance is turned over to a collection agency you understand and agree that it is not a violation of your confidentiality.

A 24-hour cancellation is required. A $45 fee will be charged per session if 24 hour policy is not complied with.
5. SERVICES ARE PROVIDED IN ACCORDANCE WITH THE FOLLOWING GUIDELINES:

You are entitled to receive information from me about my methods of therapy, the techniques I use, and the duration of your therapy.

You can seek a second opinion from another therapist or terminate therapy at any time.

In a professional relationship (such as ours), sexual intimacy between a therapist and client is never appropriate and is illegal in Colorado.
If sexual intimacy occurs, it should be reported to the Depart of Regulatory Agencies.

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 client’s consent; pursuant to Colorado Revised Statutes (CRS) § 27-10-101 et.seq.
& Standard CF.1 et.seq. There are several exceptions to confidentiality some of which are listed in CRS § 12-43-218 and in the Notice of
Privacy Rights that you were provided. These 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
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
gravely disabled, as a result of a mental disorder; (4) I am required to report any suspected threat to national security to federal officials; (5)
I am required to report any significant clinical information under court order, and; (6) in the case that I respond to any legal action taken by
you against me.
Under Colorado Law, C.R.S. § 14-10-123.8, parents have the right to access 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 HIPPA standards. In the case of shared custody between parents, it is the parent
seeking therapy for the child’s responsibility to keep the other parent informed about psychotherapy. If it is indicated, the other parent may
be required to be involved in therapy and may also be asked to sign a consent form for treatment. If may be necessary for you to assist and
encourage the involvement of the other parent.
6. CONSENT TO TREATMENT
I am requesting services from Kelly Stuerke, MSW
7. DESTRUCTION OF RECORDS:
All records about your counseling are confidential. Only authorized persons will have access to them. I understand that the clinical records from this
treatment episode may be destroyed if no further treatment is rendered within seven years of the date of termination of this episode (or ten years from
the date client reaches age eighteen, if client is a minor). A copy of your file summary can be sent to a qualified professional only by written consent
from you. You have a right to receive a copy of your file summary with a written request from you.
8. AS A CLIENT, YOU HAVE THE FOLLOWING RIGHTS:

To revoke this consent at any time.

To receive treatment only if you or your legal guardian gives permission in writing.

To be treated with respect and recognition of your need for dignity.

To receive services based on your individual needs, in a setting, which supports your individual freedoms.

To actively participate with your provider in creating a plan for your care. To include other people you think would be helpful to you in
creating your care plan.

To confidentiality, and to expect that none of the information about your treatment will be given to anyone without your permission except
as required by law.

To refuse treatment unless you are court ordered to receive services and to be informed of the consequence of your refusal.

To have your family members involved in your care, at your request. To be represented by your guardian, in the case that you are unable to
participate in your treatment decisions.

To receive written notification and request a second opinion if you disagree with your provider’s decision to reduce or discontinue your
services, or deny you inpatient services.

To not be discriminated against due to race or ethnicity, sex, age, disability, sexual orientation, genetic information or source of payment.

To be informed of the rights in a way you understand.

To complain about services at any time without retaliation.

To be informed of the complaint/grievance procedure.
Emergency Procedure: If you should need to contact me after hours or holidays feel free to call me and I will get back to you as soon as possible. If
you are in a serious crisis or have suicidal or homicidal thoughts, you can contact your local mental health center, Larimer Center for Mental Health
at 970-494-3400, North Range Behavioral Health at 970-353-3686, the Emergency Response System at 911, or go to the nearest hospital emergency
room.
By signing below, I am stating that I understand and agree to all the conditions listed and have been informed of Kelly Stuerke’s degrees,
credentials, and fees. I have read and agree to the preceding information and understand my rights as a client/patient. I also acknowledge
that I have verbally been informed of the above information. In addition, I have received a copy of the Notice of Privacy Practices. In the
case of psychotherapy with a minor child/children; I do affirm by signing this disclosure statement that I am the legal guardian and/or
custodial parent able to legally consent to the treatment of the child/children.
_______________________________________________________________________________________________________________________________________
Client Name (Please Print)
Date of Birth
_______________________________________________________________________________________________________________________________________
Client, or Legal Guardian for Minor Child Signature
Date
_______________________________________________________________________________________________________________________________________
Client, or Legal Guardian for Minor Child Signature
Date
_______________________________________________________________________________________________________________________________________
Kelly Stuerke, MSW
Date
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