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Professional Disclosure Statement

Alison McQueen, MA, LPC, ATR

Alison K. McQueen, MA, LPC, ATR

Aspenroots Counseling LLC

5378 Sterling Dr., Studio 1, Boulder, CO 80301

(303) 960-9935   alison@aspenroots.org    www.alison-mcqueen.com 

 

Background and Therapeutic Orientation: I am a mindfulness-based transpersonal counselor, somatic (body-centered) trauma specialist, and art therapist with over a decade of experience working with children, adults, families, immigrants and elders.  I have a Masters Degree in Transpersonal Counseling Psychology: Art Therapy emphasis from Naropa University and a BA in University Studies from the University of New Mexico (which included extensive work in Archetypal Art Therapy).  I have four years of international experience working in therapeutic art education in the Czech Republic, and over three years of somatic trauma training with the Somatic Training Institute in Boulder, Colorado.  I have extensive training in MDMA-assisted psychotherapy for the treatment of PTSD and spent two years as a clinical psychedelic researcher and therapist in an FDA-approved MDMA-for-PTSD study in Boulder, CO with MAPS (The Multidisciplinary Association for Psychedelic Studies).   I do not practice MDMA-assisted psychotherapy outside of the legal research context. I am practicing as a licensed professional counselor (CO LPC License #12954) and licensed art therapist (Registration #18-180). 

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 and Licensed Professional Counselors Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.

Confidentiality in Individual Therapy: Generally speaking, the information provided by and to the client during therapy sessions is legally confidential and cannot be released without the client’s consent. There are exceptions to this confidentiality, some of which are listed in section 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 and elder abuse to authorities. 

All information provided to me by you in our professional relationship is confidential except in the following circumstances: (a) you sign a release of information for a specific individual or agency; (b) child or elder abuse; (c) you are in imminent danger to self or others; (d) subpoena of records in a criminal procedure. Additionally, I may consult with a supervisor or confidential peer supervision group without disclosing identifying information. The purpose of consultation is to enhance my ability to help you, and these individuals are required to follow the same standards of confidentiality previously described.

Confidentiality in Group Therapy: The above information regarding confidentiality in individual therapy applies to group therapy as well, in terms of the client’s relationship with the therapist.  However, the therapist cannot guarantee that the content of a group session will be held confidential by all group members, although it is strongly encouraged. 

Confidentiality of Artwork: Any artwork shared during our sessions is confidential as well.  You are welcome to leave the artwork in my office, and I will provide safe and private storage for it.  The artwork is your property, however, and you are free to take it home with you as well.

Public Places and Community Gatherings: Not only are our conversations confidential; the fact that you are in therapy with me and that we know each other at all is private as well.  If we happen to see each other in public, I will protect your privacy by not acknowledging that I know you.  You are welcome to come up to me if you would like, though, and I will take my cues from you. 

Psychedelic and Cannabis Harm Reduction: I am a harm reduction advocate.  I do not encourage any illegal activities or the use or abuse of cannabis or any other medicine.  Nor do I believe that cannabis or psychedelic medicine exploration, even within the confines of applicable laws, is appropriate or beneficial for everyone.  I am a conditional advocate for intentional, sacred and non-habitual cannabis use for those individuals who already use cannabis on their own. I support my clients in making informed and educated choices about their medicine use and in developing appropriate relationships with the substances they choose to use, however my clients are solely responsible for the choices they make regarding substances. 

Telephone Calls and Emergencies: I am available to return business calls between 9am and 6pm, Monday through Friday.  I do not provide 24 hour emergency coverage. If you have an emergency please call your local 24 hour crisis line listed in the front of your phone book or call 911.

Texting: Text messages between yourself and your therapist are not appropriate.  I prefer that you email me if you need to communicate with me.  The exception to this would be if the text is brief and related to scheduling.  

Services, Fees and Payment: I offer individual therapy, as well as periodic workshops and therapy groups. An individual therapy session is $150 per hour.

Payment is expected at the time of service and may be made in cash, check, or credit card. *Please make checks payable to Aspenroots Counseling. I do not accept insurance at this time.  However, you may request invoices several times a year which can be submitted to your insurance company for possible partial reimbursement.  

Cancellations: Since I have reserved your appointment time exclusively for you, it is the policy of Aspenroots Counseling to receive at least a 24 hour cancellation notice or you will be charged for the appointment. I will consider exceptions for emergencies such as severe sudden illness on a situational basis.  *Winter weather policy: It is important that the therapeutic process not stop because of our snowy winters.  If winter weather prevents either of us from driving safely to my office, our session will take place over the phone at your scheduled time and you may mail a check to my office or pay with a credit card over the phone.

Treatment Information: You are entitled to receive information from your therapist about the methods of therapy, the techniques used, the duration of your therapy (if known), and the fee structure. You can seek a second opinion from another therapist or terminate therapy at any time. If you have any questions or would like additional information, please feel free to ask.

CONSENT TO USE, DISPLAY AND/OR PHOTOGRAPH ART THERAPY WORK PRODUCTS: I give permission to Alison McQueen, MA, LPC, ATR to use, display, and/or photograph art work created by me in a professional setting for the purpose of supervision or education about the therapeutic use of art therapy. It is my understanding that my name will not be revealed in any presentation or display of my art work.  All demographic and personal information will be kept confidential, or changed in order to maintain anonymity.

This consent may be revoked by me at any time except to the extent that action has been taken in reliance thereon.

Disclosure Statement Acknowledgement

I have read the preceding information, it has also been provided verbally, and I understand my rights as a client or as the client’s responsible party.

 

First Client's Name

First Name*

Last Name*
First Client's Date of Birth*
First Client's Information

Phone Number *
Is it okay to leave a message at this number?*
No
Yes
Is it okay to text scheduling-related messages to this number?*
No
Yes

Email Address *
Is it okay to email scheduling-related emails to this email address? Yes/No*
No
Yes

Home Address *

Emergency Contact Name *

Relationship *

Phone Number *

Email Address *

Home Address *
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

Phone Number *
Is it okay to leave a message at this number?*
No
Yes
Is it okay to text scheduling-related messages to this number?*
No
Yes

Email Address *
Is it okay to email scheduling-related emails to this email address? Yes/No*
No
Yes

Home Address *

Emergency Contact Name *

Relationship *

Phone Number *

Email Address *

Home Address *
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

Phone Number *
Is it okay to leave a message at this number?*
No
Yes
Is it okay to text scheduling-related messages to this number?*
No
Yes

Email Address *
Is it okay to email scheduling-related emails to this email address? Yes/No*
No
Yes

Home Address *

Emergency Contact Name *

Relationship *

Phone Number *

Email Address *

Home Address *
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Phone Number *
Is it okay to leave a message at this number?*
No
Yes
Is it okay to text scheduling-related messages to this number?*
No
Yes

Email Address *
Is it okay to email scheduling-related emails to this email address? Yes/No*
No
Yes

Home Address *

Emergency Contact Name *

Relationship *

Phone Number *

Email Address *

Home Address *
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Phone Number *
Is it okay to leave a message at this number?*
No
Yes
Is it okay to text scheduling-related messages to this number?*
No
Yes

Email Address *
Is it okay to email scheduling-related emails to this email address? Yes/No*
No
Yes

Home Address *

Emergency Contact Name *

Relationship *

Phone Number *

Email Address *

Home Address *
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Phone Number *
Is it okay to leave a message at this number?*
No
Yes
Is it okay to text scheduling-related messages to this number?*
No
Yes

Email Address *
Is it okay to email scheduling-related emails to this email address? Yes/No*
No
Yes

Home Address *

Emergency Contact Name *

Relationship *

Phone Number *

Email Address *

Home Address *
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Phone Number *
Is it okay to leave a message at this number?*
No
Yes
Is it okay to text scheduling-related messages to this number?*
No
Yes

Email Address *
Is it okay to email scheduling-related emails to this email address? Yes/No*
No
Yes

Home Address *

Emergency Contact Name *

Relationship *

Phone Number *

Email Address *

Home Address *
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Phone Number *
Is it okay to leave a message at this number?*
No
Yes
Is it okay to text scheduling-related messages to this number?*
No
Yes

Email Address *
Is it okay to email scheduling-related emails to this email address? Yes/No*
No
Yes

Home Address *

Emergency Contact Name *

Relationship *

Phone Number *

Email Address *

Home Address *
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Phone Number *
Is it okay to leave a message at this number?*
No
Yes
Is it okay to text scheduling-related messages to this number?*
No
Yes

Email Address *
Is it okay to email scheduling-related emails to this email address? Yes/No*
No
Yes

Home Address *

Emergency Contact Name *

Relationship *

Phone Number *

Email Address *

Home Address *
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Phone Number *
Is it okay to leave a message at this number?*
No
Yes
Is it okay to text scheduling-related messages to this number?*
No
Yes

Email Address *
Is it okay to email scheduling-related emails to this email address? Yes/No*
No
Yes

Home Address *

Emergency Contact Name *

Relationship *

Phone Number *

Email Address *

Home Address *
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Phone Number *
Is it okay to leave a message at this number?*
No
Yes
Is it okay to text scheduling-related messages to this number?*
No
Yes

Email Address *
Is it okay to email scheduling-related emails to this email address? Yes/No*
No
Yes

Home Address *

Emergency Contact Name *

Relationship *

Phone Number *

Email Address *

Home Address *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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