Sashi Gollub, Registered Psychotherapist
Uncovering your strength, clarity and wisdom through present moment exploration
Disclosure and Practice Policies Statement
Welcome to my practice. This document contains important information about my
professional services and business policies. Please read it carefully and feel free to discuss any
questions that you might have with me.
Therapist (Education and Training)
I am a Registered Psychotherapist in the state of Colorado (#0104308). I will receive a
Master of Arts in Transpersonal Counseling Psychology from Naropa University this May
2014. I received my Bachelors of Fine Arts from New York University, with a
Concentration in Theatre in June 2008.
Professional Certifications, Registrations, and Trainings
 Meditation Instructor Training, January 2014
Naropa University, Boulder, CO
 Introduction to Spiral Dynamics, November, 2013
Noeticus Counseling Center and Training Institute, Denver, Co
 Pragmatic Experiential Therapy for Couples, September 2013
Noeticus Counseling Center and Training Institute, Denver, Co
 Dialectical Behavior Therapy (DBT), July 2013
Noeticus Counseling Center and Training Institute, Denver, Co
 Qualified Medication Administration Person (QMAP) Training, September, 2012
Mental Health Partners, Boulder, CO
 Hospice End-of-Life Care Training, September 2009
Visiting Nurse Services, New York, NY
 Yoga Teacher Certification (500 hours), June 2009
ISHTA Yoga Studio, New York, NY
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. The Board of
Registered Psychotherapists Examiners 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.
Sashi Gollub, Registered Psychotherapist
Uncovering your strength, clarity and wisdom through present moment exploration
•
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 bachelor’s degree in
behavioral health, complete additional required training hours and 2,000 hours of
supervised experience.
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Licensed Addiction Counselor must have a clinical master’s degree and meet the
CAC III requirements.
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Licensed Social Worker must hold a master’s degree in social work.
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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.
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Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a
Licensed Professional Counselor must hold a master’s degree in their profession
and have two years of post- masters supervision.
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A Licensed Psychologist must hold a doctorate degree in psychology and have one
year of post- doctoral supervision. Client Information -At any time you may ask about the methods of therapy, techniques I
use, duration of your therapy, if known, and my fee structure. You may always seek a second
opinion from another therapist or terminate therapy at any time. If I feel that I am unable
to assist you adequately, I reserve the right to suggest a referral option. In a professional
relationship, sexual intimacy between a therapist and a client is never appropriate and should
be immediately reported to the board that licenses, registers, or certifies the licensee,
registrant or certificate holder.
Confidentiality -Generally speaking, information provided by a client during therapy
sessions is legally confidential and cannot be released without your consent. You should
know, however, that there are exceptions to this confidentiality, some of which are listed in
sections 12-43-218 of the Colorado Revised Statutes as well as other exceptions in Colorado
and Federal law. For example, mental health professionals are required to report suspected
child abuse to authorities. If a legal exception arises during therapy, if feasible, you will be
informed accordingly. The Mental Health Practice act (CRS 12-43-101 et seq.) is available at
Sashi Gollub, Registered Psychotherapist
Uncovering your strength, clarity and wisdom through present moment exploration
http:// www.dora.state.co.us/mental-health/Statute.pdf Fees and Payment Policies
Professional Fees- Fee for services is ___ per 50-minute session due in full at the end of
each session. Sessions of varying lengths (60-75-90 minutes) are available depending upon
your goals and are charged a pro-rated hourly rate of ___. I am not associated with any
insurance company and do not accept insurance reimbursement directly. As such, I am
considered an out-of-network provider. I encourage you to consult directly with your
insurance company regarding your benefits. Since my time has been scheduled specifically
for you, cancellations made less than 24 hours in advance will be charged to your
account________ (Initials)
Emergencies -As a therapist in outpatient private practice, I do not provide 24 hour
emergency services. If you need emergency assistance please call 911, or go to your nearest
emergency room.
Telephone Calls - I check my messages regularly, and I will make every effort to return
calls as promptly as possible. I may not be able to do so on weekends, holidays, and personal
vacations. Unless other arrangements have been made, I charge for conversations lasting
longer than 10 minutes.
Therapeutic Touch – I am a certified Yoga teacher, which means I have been trained
specifically with therapeutic touch, and can utilize it when clinically recommended. This
method is experientially based and utilizes mindfulness in conjunction with body awareness.
When employing this method, the therapist may occasionally suggest a non-invasive form of
touch as part of the work. This touch is not required, and would only be applied with
permission by you, the client. If at any time the touch is not helpful in supporting your
process, please let me know, as I will stop immediately.
By your signature below, you are indicating that you have read and understood the preceding
information, it has been provided to you verbally, and that you understand your rights as a
client, and agree to participate in treatment within the guidelines set forth here. If you have
any questions or would like additional information, please feel free to ask.
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________________________________ Sashi Gollub, Therapist
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