PSYCHOTHERAPY PRACTICE POLICY STATEMENT AND INFORMED CONSENT FORM
Welcome to Kokokara Therapy, Inc. with Nanae Ito. I am a Licensed Clinical Social Worker (Colorado, #CSW.09926654 and Alaska, #204189). This document contains important information about my professional services and business policies. Please read it carefully and discuss any questions you may have with me. When you sign this document, it will represent an agreement between us. Please make a copy of this agreement for your records.
PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and patient(s), and the particular issues you bring forward. There are many different methods I may use to deal with the questions that you hope to address. My primary method is somatic psychotherapy which is a form of body-centered therapy that looks at the connection of mind and body and uses both talk-therapy and physical practices for holistic healing.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness as well as physical sensations. On the other hand, therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.
CANCELLATIONS AND MISSED APPOINTMENTS
Consistency is key to the therapeutic process. To maintain this consistency, I have a no-cancelation policy. This policy protects the time I set aside specifically for you, as my client, and ensures that I have a predictable and consistent schedule that allows me to do my best work. Your scheduled hour is your financial responsibility; therefore, you agree to pay for your appointment, regardless of whether you choose to come.
You can reschedule your appointment anytime during the week before, during, or after your absence (a three week window) if our schedules align. I will make every effort to find a time for you. In order to reschedule your session, you must give 24-hours notice, otherwise you are responsible for your fee and I cannot reschedule the canceled appointment.
If you cancel your appointment, you will be charged the full fee by the end of the day of the canceled appointment using the card that you have on file via your online portal. For those utilizing their insurance benefits, if an appointment is canceled, you will be charged the full fee by the end of the day of the canceled appointment using the card that you have on file via your online portal.
You are allotted one free cancellation per calendar year for each time that you attend per week. For example, if you attend therapy twice per week, you are given two free cancellations. For this freebie, you can cancel at any time before the session without advance notice. You are not required to pay for sessions that I cancel or when my office is closed. I will make every effort to alert you of my planned vacation times in advance.
VIRTUAL/TELEPHONE SESSIONS
All sessions are currently conducted via telemental health. Please refer to the Telemental Health Informed Consent Form for additional information.
PROFESSIONAL FEES
My hourly fee is $200 per 50-minute session for individuals. I do raise my fees periodically. When my fees change, I will provide at least a 30 day advance notice.
In addition to scheduled sessions, I reserve the right to charge the same rate (I will break down the hourly cost) for other professional services that you may require, such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations, or the time required to perform any other service which you may request of me. We will discuss these circumstances as they arise.
Currently, I am credentialed with Aetna and United HealthCare through the state of Colorado and utilize Alma for claim submission: https://secure.helloalma.com. You are responsible for your co-pay per session which is paid through the Alma portal.
BILLING AND PAYMENTS
I require a credit or debit card to be on file via your online portal. You will be charged for each session on the day it is held, unless we make other arrangements.
If you wish to seek reimbursement through your insurance and I am out-of-network, I will provide a superbill at the end of each month for you to submit directly to your provider. Note that a mental health diagnosis will be required which will be discussed and determined collaboratively during our initial session(s).
GOOD FAITH ESTIMATES
As of January 1, 2022, all health care providers are required to provide a good faith estimate to any person who is receiving services, and who is not using insurance or doesn’t have insurance for those services.
The No Surprises Act was created to avoid consumers receiving a “surprise” bill from an out of network provider, when they thought the services they were receiving would be covered by their in network insurance benefits. It is intended to make it easier to understand all that you will be billed.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item.You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.
SOCIAL MEDIA AND REVIEW WEBSITES
If you try to communicate with me via these methods, I will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy. I may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow me on any platform, I will not follow you back.
If you see me on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include me. If you choose to leave a review on any website, I will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing in other places without your knowledge.
TELEPHONE & EMERGENCY PROCEDURES
If you need to contact me between sessions, you may leave a message on my voicemail. Please leave your telephone number. I will return your call within 48 hours, Monday-Thursday. If an emergency arises, please indicate this clearly in your message and, if necessary, call 911. You may also send me an email or text. Please be aware, email or text is not a confidential form of communication. Email or text may be used primarily for scheduling purposes. We will not conduct psychotherapy via email or text.
CONFIDENTIALITY
Your sessions with me are confidential. With the exceptions outlined below, your identity will be kept private. The information we discuss may be shared in a confidential manner under the following circumstances:
When I am away, another mental health professional may cover my practice. With your consent, that person will be informed about your circumstances and may be given your name and phone number. They will maintain your confidentiality per Colorado or Alaska state law.
As part of my standard of care, I regularly seek consultation with qualified mental health professionals. If I seek consultation about your treatment, your identifying information will remain confidential.
Colorado state law requires that the following exceptions be made to your right to confidentiality: a) child abuse or neglect; b) abuse of an elder or disabled individual; c) a threat to the life of another person; d) if, due to a mental disorder, you are in imminent danger of harming yourself or you are gravely disabled (unable to provide yourself with food, clothing or shelter).
If you become involved in legal disputes, the court can subpoena your records. In such cases, you and I will think about how to proceed.
TELEMENTAL HEALTH INFORMED CONSENT
I hereby consent to participate in telemental health with Nanae Ito, LCSW of Kokokara Therapy, Inc. as part of my psychotherapy. I understand that telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.
I understand the following with respect to telemental health:
I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
I understand that there are risks and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required.
I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call me at 720-505-0594 to discuss since we may have to re-schedule.
I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.
Emergency Protocols
I need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life-threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency.
This information will be pulled from your new client intake form.
I have read the information provided above and discussed it with my therapist. I understand the information contained in this form and all of my questions have been answered to my satisfaction.
MANDATORY DISCLOSURE STATEMENT
Business Information
Nanae Ito, LCSW
Kokokara Therapy, Inc.
PO Box 100793, Denver, CO 80250
(720) 505-0594
An explanation of the levels of regulation applicable to mental health professionals under the Mental Health Practice Act and the differences between licensure, unlicensed registration, and certification, including the educational, experience, and training requirements applicable to the particular level of regulation.
A Licensed Clinical Social Worker must hold a master’s or doctorate degree from a graduate school of social work, have at least two years post-master’s or post- doctoral practice under supervision, and pass a national examination in social work.
A Licensed Social Worker must hold a master’s degree or doctorate degree from a graduate school of social work and pass a national examination in social work.
A Clinical Social Worker Candidate, Psychologist Candidate, a Marriage and Family Therapist Candidate, a Licensed Professional Counselor Candidate, and an Addictions Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision and post-degree practice for licensure.
A Licensed Marriage and Family Therapist must hold a master’s or doctoral degree in marriage and family counseling, have at least two years post-master’s or one-year postdoctoral practice under supervision, and pass a national exam in marriage and family therapy.
A Licensed Professional Counselor must hold a master’s or doctoral degree in professional counseling, have at least two years post-master’s or one-year postdoctoral practice under supervision, and pass a national exam in in professional counseling.
A Licensed Psychologist must hold a doctorate degree in psychology, have one year of postdoctoral supervision and practice, and pass a national examination in psychology.
A Certified Addiction Technician (ACA) must be a high school graduate or equivalent, complete 1,000 hours of supervised work experience in no less than 6 months, and pass the NAADAC Level I exam.
A Certified Addiction Specialist (ACC) must have a clinical behavioral health bachelor’s degree, complete 2,000 hours of supervised work experience in no less than 12 months (may include experience gained/used for ACA credential), and pass the NAADAC Level II exam.
A Licensed Addiction Counselor must have a clinical master’s or doctoral degree, meet the requirements for ACC, and have 3,000 hours of clinical work experience, in which a minimum of 2,000 hours must be supervised, and pass the NAADAC Master Addiction Counselor (MAC) exam.
An Unlicensed 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.
Professional Credentials
Licensed Clinical Social Worker, Colorado, #CSW.09926654
Licensed Clinical Social Worker, Alaska, #204189
Certified Clinical Trauma Professional - I, Arielle Schwartz, 2023
Certificate in Somatic Embodiment & Regulation Strategies, Linda Thai, 2022
Master of Social Work, 2017, University of Denver, Graduate School of Social Work
Bachelor of Arts, Sociology, 2010, University of Alaska, Fairbanks
The practice of licensed or unlicensed registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Professions and Occupations. The Board of Social Work Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.
AND
The Department of Commerce, Community, and Economic Development - Division of Corporations, Business, and Professional Licensing. The Board of Social Work Examiners can be reached at PO Box 110806, Juneau, AK 99811-0806, (907) 456-2550.
The client is entitled to receive information about the methods of therapy, the techniques used, the duration of therapy, if known, and the fee structure.
The client may seek a second opinion from another therapist or may terminate therapy at any time.
In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licensed, registers, or certifies the licensee, unlicensed registrant, or certificate holder.
The information provided by the client during therapy sessions is legally confidential in the case of licensed marriage and family therapists, social workers, professional counselors, and psychologists; licensed or certified addiction counselors; and unlicensed psychotherapists, except as provided in §12-245-220 and except for certain legal exceptions that will be identified by the licensee, unlicensed registrant, or certificate holder should any such situation arise during therapy. Some examples include:
Child or At-Risk Adult Abuse: If I have reasonable cause to know or suspect that a child has been subjected to abuse or neglect or an at-risk adult has been mistreated, self-neglected, or financially exploited or is at imminent risk of mistreatment, self-neglect, or financial exploitation, then I must report this to the appropriate authorities.
Health Oversight Activities: If the Colorado state licensing board or an authorized professional review committee is reviewing my services, I may disclose PHI to that board or committee.
Judicial and Administrative Proceedings: If you are involved in a court proceeding where you are being evaluated for a third party or where the evaluation is court ordered, I may disclose PHI to the court. You will be informed in advance if this is the case.
Serious Threat to Health or Safety: If you communicate to me a serious threat of imminent physical violence against a specific person or persons, including those identifiable by association with a specific place, I have a duty to notify any person or persons specifically threatened, as well as a duty to protect by taking other appropriate action. If I believe that you are at imminent risk of inflicting serious harm on yourself, I may disclose information necessary to protect you. In either case, I may disclose information in order to initiate hospitalization.
Business Associates: Kokokara Therapy may enter into contracts with business associates to provide billing, legal, auditing, and practice management services that are outside entities. In those situations, protected health information will be provided to those contractors as is needed to perform their contracted tasks. Business associates are required to enter into an agreement maintaining the privacy of the protected health information released to them.
In Compliance with Other State/Federal Laws and Regulations: PHI may be disclosed when the use and disclosure is allowed under other sections of Section 164.512 of the Privacy Rule and the state’s confidentiality law. This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS), to a medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions (fitness for military duties, eligibility for VA benefits, etc.)
Your client records may not be maintained after seven years pursuant to §12-245-226(1)(a)(II)(A).
I have read the preceding information and understand my rights as a client or as the client’s responsible party.