Downloads & Intake Forms
New Patient Intake Form
HIPAA Release Form
Self Pay - $80 per session
Information for New Patients
Rachel Bolenbaugh obtained a Master's Degree in Marriage, Family, and Child Therapy through the University of Phoenix at Colorado Springs, CO and met all of the DORA requirements in education, training, and experience to become a Licensed Marriage, Family, and Child Therapist. Marriage, Family, and Child Licensure number (LMFT) 0001555 issued 07/2018. At any time, you are entitled to receive information about the method of therapy, techniques used, anticipated duration of treatment, and fees to be charged at any time you so request. At any time, you, as the client, may seek a second opinion from another therapist or may terminate therapy at any time.
A 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.
A Certified Addiction Counselor I (CAC I) must be a high school graduate or equivalent, complete required training hours and 1,000 hours of supervised experience.
A Certified Addiction Counselor II (CAC II) must be a high school graduate or equivalent, complete the CAC I requirements, and obtain additional required training hours, 2,000 additional hours of supervised experience, and pass a national exam.
A Certified Addiction Counselor III (CAC III) must have a bachelor's degree in behavioral health, complete CAC II requirements, and complete additional required training hours, 2,000 additional hours of supervised experience, and pass a national exam.
A Licensed Addiction Counselor must have a clinical master's degree, meet the CAC III requirements, and pass a national exam.
A Licensed Social Worker must hold a master's degree from a graduate school of social work and pass an examination in social work.
A Licensed Clinical Social Worker must hold a master's or doctorate degree from a graduate school of social work, practiced as a social worker for at least two years, and pass an examination in social work.
A 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.
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 post-doctoral practice, and pass an 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, and pass an exam in in professional counseling.
A Licensed Psychologist must hold a doctorate degree in psychology, have one year of post-doctoral supervision, and pass an examination in psychology.
You have the right to confidential treatment. There are exceptions to this confidentiality, some of which are listed in section 12-43-218 of the Colorado Revised Statutes for Licensed Marriage and Family therapist, social workers, professional counselors, and psychologists, licensed or certified addiction counselors and registered psychotherapists, the HIPAA Notice of Privacy Rights you were provided, as well as other exceptions in Colorado and Federal law. Confidentiality is maintained unless you become an imminent danger to yourself or another person, and then only minimal information is shared to facilitate your or another's safety. Confidentiality also will be waived automatically in cases involving child abuse, child sexual abuse, grave emotional disability or criminal behavior. Every effort will be made to minimize the data shared with other professionals or authorities, including your Primary Care Physician. You have the right to terminate treatment at any time and you also may request a second opinion at any time.
Sexual contact between client and therapist is not part of any recognized therapy. Sexual intimacy between client and therapist is illegal in Colorado and should be reported to the Grievance Board. If you have any questions, concerns or complaints about licensed or unlicensed mental health practitioners, you can contact the State Grievance Board at 1560 Broadway, Suite 1340, Denver, CO 80202, or at (303) 894-7800.
If an appointment is made, please give 24 hours cancellation notice. When you accept an appointment time, you are making a commitment to your therapist to be there on that scheduled day and time. When you fail to keep an appointment that time is lost to you, the therapist, and to other patients and you will be billed a $50 fee. If keeping your appointments becomes a problem and we are not able to resolve this then I do reserve the right to charge you personally for your missed appointment.
In an emergency, you may call the Colorado Crisis Line at 844-493-8255 or text 38255.
I understand the risks of communicating via text and/or email, that they are non-secured forms of communication.
You may bill your insurance yourself or my billing company will bill it for you. If you have an insurance copayment, coinsurance, or an unmet deductible, you will be expected to make this payment at EACH visit, unless other payment arrangements have previously been made. Past due personal accounts will be charged a finance charge of 1.5% monthly. Returned checks will be assessed at $15.00 plus any bank charges. Long overdue or delinquent accounts will be turned over to an attorney or collection agency for collection and/or legal proceedings. You will be responsible for legal fees entailed in that process. Your name, address, employment, phone, and balanced owed will be provided to the collection agency or attorney. I have read all the above New Patient Information and I understand my rights as a client or as the client's responsible party. This information was also verbally reviewed with patient.
NOTICE OF PRIVACY PRACTICES
Health Insurance Portability and Accountability Act (HIPAA)
The privacy of your health information is important to me. I will maintain the privacy of your health information and I will not disclose your information to others unless you tell me to do so, or unless the law authorizes or requires me to do so.
Federal law commonly known as HIPAA requires that I take additional steps to keep you informed about how I may use information that is gathered in order to provide health care services to you. As part of this process, I am required to provide you with the attached Notice of Privacy Practices and to request that you sign the attached written acknowledgment that you received a copy of the Notice. The Notice describes how I may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. This Notice also describes your rights regarding health information I maintain about you and a brief description of how you may exercise these rights.
If you have any questions about this Notice please contact Rachel Bolenbaugh, MS, LMFT
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THE INFORMATION CAREFULLY.
I am required by applicable federal and state law to maintain the privacy of your health information. I am also required to give you this Notice about my privacy practices, legal obligations and your rights concerning your health information ("Protected Health Information" or "PHI"). I must follow the privacy practices that are described in this Notice (which may be amended from time to time).
For more information about my privacy practices, or for additional copies of this Notice, please contact me using the information listed in Section II G of this Notice.
I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
A. Permissible Uses and Disclosures without Your Written Authorization
I may use and disclose PHI without your written authorization, excluding Psychotherapy Notes as described in Section II, for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under federal and state law.
I may use and disclose PHI in order to provide treatment to you. For example, I may use PHI to diagnose and provide counseling services to you and leave appropriate messages for you regarding your appointment. In addition, I may disclose PHI to other health care providers involved in your treatment.
I may use or disclose PHI so that services you receive are appropriately billed to, and payment is collected from, your health plan. By way of example, I may disclose PHI to permit your health plan to take certain actions before it approves or pays for treatment services.
Health Care Operations:
I may use and disclose PHI in connection with our health care operations, including quality improvement activities, training programs, accreditation, certification, licensing or credential activities.
Required or Permitted by Law:
I may use or disclose PHI when I am required or permitted to do so by law. For example, I may disclose PHI to appropriate authorities if I reasonably believe that you are a possible victim of other crimes. In addition I may disclose PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Other disclosures permitted or required by law include the following: disclosures for public health activities; health oversight activities including disclosures to state or federal agencies authorized to access PHI; disclosures to judicial and law enforcement officials in response to a court order or other lawful process; disclosures for research when approved by an institutional review board; and disclosers to military or national security agencies, coroners, medical examiners, and correctional institutions or otherwise authorized by law.
B. Uses and Disclosures Requiring Your Written Authorization
Notes recorded by your clinician documenting the contents of a counseling session with you (Psychotherapy Notes) will be used only by your clinician and will not otherwise be used or disclosed without your written authorization.
I will not use your health information for marketing communications without your written authorization.
Other Uses and Disclosures:
Uses and disclosures other than those described in Section I.A. above will only be made with your written authorization. For example, you will need to sign and authorization form before I can send PHI to your life insurance company, to a school, or to your attorney. You may revoke any such authorization at any time.
II. YOUR INDIVIDUAL RIGHTS
Right to Inspect and Copy: You may request access to your medial record and billing records maintained by me in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, I may deny access to your records. I may charge a fee for the costs of copying and sending you any records requested. If you are a parent or legal guardian of a minor, please note that certain portions of the minor's medical record will not be accessible to you (e.g., records related to mental health, drug treatment, or family planning services).
Right to Alternative Communications: You may request, and I will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.
Right to Request Restrictions: You have the right to request a restriction on PHI used for disclosure for treatment, payment or health care operations. You must request any such restriction in writing addressed to the Privacy Officer as indicated below. I am not required to agree to any such restriction you may request.
Right to Accounting of Disclosures: Upon written request, you may obtain an accounting of certain disclosures of PHI made by me after April 14, 2003. This right applies to disclosures for purposes other than treatment, payment or health care operations, excludes disclosures made to you or disclosures otherwise authorized by you, and is subject to other restrictions and limitations.
Right to Request Amendment: You have the right to request that I amend your health information. Your request must be in writing, and it must explain why the information should be amended. I may deny your request under certain circumstances.
Right to Obtain Notice: You have the right to obtain a paper copy of this Notice by submitting a request to the Privacy Officer at any time.
Questions and Complaints: If you desire further information about your privacy rights, or are concerned that I have violated your privacy rights, you may contact the Privacy Officer, Rachel Bolenbaugh, LMFT at 719-510-3899. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. I will not retaliate against you if you file a complaint with the Director or me.
III. EFFECTIVE DATE AND CHANGES TO THIS NOTICE
Effective Date: This Notice is effective on April 14, 2003.
Changes to this Notice: I may change the terms of this Notice at any time. If I change this Notice, I may make the new Notice terms effective for all PHI that I maintain, including any information created or received prior to issuing the new Notice. If I change this Notice, I will post the revised Notice on my website. You may also obtain any revised Notice by contacting me.
Explanation of Fees
$80.00 Initial Session
$80.00 Individual Session
$80.00 Family Session with or without patient
$20.00 Group Therapy
No-Shows and late cancellations (less than 24 hour notice) are billed $80.
Phone calls and voice mail messages are billed as follows:
$20.00 for 1-15 minutes
$40.00 for 16-30 minutes
$60.00 for 31-45 minutes
$80.00 for 46-60 minutes
This includes collateral contact (i.e. necessary communications with other people involved in this case.)
$25.00 minimum charge for letter writing
$25.00 minimum charge for file copying
$75.00 per hour charge for staffing
$75.00/hour for review of records and documents
$75.00 per hour for court preparation
$250.00 per hour for expert testimony (2 hour minimum)
$100.00 per hour portal to portal fee
Court costs are payable in advance and are non-refundable.
Electronic Signature Agreement
By selecting 'I agree', typing your name below and selecting the "I Accept" button, you are signing these disclosures electronically. You agree your electronic signature is the legal equivalent of your manual signature on this disclosure. By selecting "I Accept" you consent to be legally bound by these disclosures terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide Rachel Bolenbaugh Counseling, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and Rachel Bolenbaugh Counseling.
Select 'I agree' to the Disclosures
I have hereby read all the above New Patient Information and I understand completely and agree to the disclosures.
I have hereby read and understand the above fees and agree to these charges as listed.
I have hereby read and understand and agree to the HIPAA disclosure.
Name of Client:
If you are the Parent E-Signing for your Child, please Type Your Name.
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