Office Policies

This form provides you (patient) with information that is additional to that detailed in the Notice of Privacy Practices, and it is subject to HIPAA pre-emptive analysis. (Revised 9/2022)

 Confidentiality: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law. (Please see additional information regarding confidentiality and minors in therapy).

When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder abuse or neglect; where a client presents a danger to self, to others, to property or is gravely disabled or when client’s family members communicate to Ms. van Rijssen that the client presents a danger to others.

When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Ms. van Rijssen. In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. Ms. van Rijssen will use her clinical judgment when revealing such information. Ms. van Rijssen will not release records to any outside party unless she is authorized to do so by all adult family members who were part of the treatment.

Emergencies: If there is an emergency during our work together, or in the future after termination where Ms. van Rijssen becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, she will do whatever she can, within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose she may also contact the person whose name you have provided on the biographical sheet.

Minors in Therapy: If you are under eighteen years of age, please be aware that the law may give your parents or guardians the right to obtain information about your treatment and/or examine your treatment records. It is part of Ms. Van Rijssen’s policy to request a written agreement from your parents or guardians (through signature of this form) indicating that they consent to give up access to such information and/or to your records. If they agree, information will only be provided generally about work together, subject to your approval.

If Ms. Van Rijssen ever feels there is a high risk that you will seriously harm yourself or another/others, or if disclosure involves information that Ms. Van Rijssen is required by law to report – parents will be involved. Before giving them any verbal or written information, Ms. Van Rijssen will discuss the matter with you, if possible, doing her best to resolve any differences that may exist about what will be discussed. Ms. Van Rijssen feels is important to provide a “zone of privacy” for children and adolescents to help develop and maintain trust and growth in therapy. There are times however, when by law confidentiality would have to be broken, and these include: concerns/reports/knowledge of abuse, incest, neglect, rape, and of emailing/texting sexual images. In these instances parents would be notified as well as appropriate regulatory and protective agencies.

If your child is an adolescent, it is possible that during the course of therapy they may reveal sensitive information regarding sexual contact, alcohol and drug use, or other behaviors. Sometimes these behaviors will fall within the range of normal adolescent experimentation, but at other times, may require parental intervention. During the initial parent session, clear and direct discussion of what your individual opinions are regarding acceptable behavior will be explored.

Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on Ms. van Rijssen to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.

Consultation: Ms. van Rijssen consults regularly with other professionals regarding her clients; however, client’s identity remains completely anonymous, and confidentiality is fully maintained.

E – Mails, Cell Phones, Computers and Faxes: It is very important to be aware that computers and e-mail and cell phone communication can be relatively easily accessed by unauthorized people and, hence, can compromise the privacy and confidentiality of such communication. E-mails in particular are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Additionally, Ms. van Rijssen’s e-mails are not encrypted. Faxes can easily be sent erroneously to the wrong address. Ms. van Rijssen’s computer is equipped with a firewall, a virus protection and a password and she also backs up all confidential information from her computers onto a hard drive on a regular basis. The hard drive is stored securely off-site. Please notify Ms. van Rijssen if you decide to avoid or limit, in any way, the use of any or all communication devises, such as e-mail or cell phone. Please do not use e-mail for emergencies. Texting may be used for appointment reminders but please do not send any other information via text.

Records and Your Right to Review Them: Both the law, and the standards of the therapeutic profession require that appropriate treatment records be kept. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when Ms. van Rijssen assesses that releasing such information might be harmful in any way. In such a case Ms. van Rijssen will provide the records to an appropriate and legitimate mental health professional of your choice.

Telephone & Emergency Procedures: If you need to contact Ms. van Rijssen between sessions, please leave a message on her private confidential voicemail (303) 842-3880 and your call will be returned as soon as possible. Ms. Van Rijssen is not an “on call” therapist. Ms. van Rijssen checks her messages a few times during the daytime hours only, unless she is out of town. If an emergency situation arises, indicate it clearly in your message, and if you need to talk to someone right away, call the mental health crisis line at 1-800-273-TALK or dial 911. Please do not use e-mail or texts in emergencies. Ms. van Rijssen does not always check her e-mail daily.

Inclement Weather: If weather becomes severe and travel to/from the appointment may become unsafe due to conditions, Ms Van Rijssen will contact you to re-schedule session times.

Payments & Insurance Reimbursement: Clients having individual sessions are expected to pay the standard fee of $180.00 per 55 minute session at the end of each session, unless other arrangements have been made. Telephone conversations, telephone sessions, emails, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify Ms. van Rijssen if any problems arise during the course of therapy regarding your ability to make timely payments. Ms. van Rijssen does not bill to insurance companies but will provide a superbill with appropriate codes reflecting sessions rendered for clients to submit themselves. Parent sessions to check in regarding treatment of minors is a required part of therapy. These sessions may be in person or by phone and are billed at the same rate of $180.00 her 55 minute hour. The parent receiving session is responsible for payment. Invoices may be emailed for convenience of client and are due upon receipt. A $30 late fee will be added to any invoice over 3 days past due.

The Process of Therapy/Evaluation and Scope of Practice: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty and openness in order to change your thoughts, feelings and/or behavior. Ms. van Rijssen will ask for your feedback and views on your therapy, its progress and other aspects of the therapy and will expect you to respond openly and honestly. During evaluation or therapy, remembering or talking about unpleasant events, feelings or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc, or experiencing anxiety, depression, insomnia, etc. Ms. van Rijssen may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about or handling situations. This can cause you to feel very upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy Ms. van Rijssen is likely to draw on various psychological approaches according, in part, to the problem that is being treated and her assessment of what will best benefit you. These approaches include, but are not limited to, art therapy, cognitive-behavioral, system/family, developmental (adult, child, family), and humanistic. Ms. van Rijssen provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within her scope of practice.

Discussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment Ms. van Rijssen will discuss with you (client) her working understanding of the problem, treatment plan, therapeutic objectives and her view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, Ms. van Rijssen’s expertise in employing them or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that Ms. van Rijssen does not provide, she has an ethical obligation to assist you in obtaining those treatments.

Termination: As set forth above, after the first couple of meetings Ms. van Rijssen will assess if she can be of benefit to you. Ms. van Rijssen does not accept clients who, in her opinion, she cannot help, or who require therapy outside of her scope of practice. In such a case she will give you a number of referrals, which you can contact. If at any point during psychotherapy, Ms. van Rijssen assesses that she is not effective in helping you reach the therapeutic goals, she is obligated to discuss it with you and, if appropriate, to terminate treatment. In such a case she would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, Ms. van Rijssen will talk to the psychotherapist of your choice in order to help with the transition. You have the right to terminate therapy at any time for yourself, or for your minor client, however, Ms. Van Rijssen requests to have 1-2 last sessions to provide a therapeutic ending, as this is best practice.

Dual Relationships: Not all dual relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs Ms. van Rijssen’s objectivity, clinical judgment or therapeutic effectiveness or can be exploitive in nature. You may bump into someone you know in the waiting room or into Ms. van Rijssen out in the community. Ms. van Rijssen will never acknowledge working with anyone without his/her written permission. Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it, and often it is impossible to know that ahead of time. It is your, the client’s, responsibility to communicate to Ms. van Rijssen if the dual relationship become uncomfortable for you in any way. Ms. van Rijssen will always listen carefully and respond accordingly to your feedback and will discontinue the dual relationship if she finds it interfering with the effectiveness of the therapy or the welfare of the client, and of course you can do the same at any time.

Cancellation: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification.

I have read the above Agreement, Informed Consent, Office Policies and General Information carefully, (total 3 pages) I understand them and agree to comply with them: