Teletherapy Disclosure Statement

WELCOME! Before you begin receiving services there is some important information we are required by the Colorado State Department of Regulatory Agencies and other governing bodies to review with you. Please read through this document carefully, ask your therapist about information that seems unclear before you begin counseling or at any time, and sign the last page of the statement. A copy of this form will be placed in your file.

Your Rights: As licensed therapists, we desire to integrate sound psychological principles in your treatment. You are entitled to receive information from any therapist concerning our methods of therapy, the techniques used, an estimation of the duration of your treatment, risks and benefits of counseling, confidential communication and access to your records. You also have the right to know what other treatment options are available and the possible effectiveness of those alternatives. You may at any time seek a second opinion from another clinician and/or terminate the counseling process. Therapists need to be informed if you are working with more than one counselor. In a professional relationship with a therapist, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies that therapist.

HIPAA provides you with several new or expanded rights regarding your Clinical Record and disclosures of protected health information. These rights include requesting that your therapist amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of any disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to another copy of this Notice upon request.

Minors & Parents: Under Colorado law, C.R.S. 14-10-123.8, parents have the right to access mental health treatment information concerning their minor children unless the court has restricted access to such information. If you request treatment information, the therapist may provide you with a treatment summary in compliance with Colorado law and HIPAA standards.

Disclosure of Experience, Degrees, Licensing and other Certifications: You have the right to be informed regarding the degrees, credentials, certifications, registrations, and licenses held or obtained by your therapist. This includes the education, experience and training that were required to satisfy the degrees, credentials, certifications, registrations and licenses. We have four licensed therapists who are working through our teletherapy program:

Charles Mayer-Twomey
Licensed Clinical Social Worker (LCSW)
Masters Degree in Social Work with a specialization in Community Mental Health (MSW), Colorado License Number: 09924139, California License Number: 29373 Charles Mayer-Twomey, LCSW– Charlie is a licensed clinical social worker and board certified with the State of Colorado and the State of California. He has worked with children, adolescents and families for over 15 years. Charlie earned his master’s degree in Social Work from California State University East Bay in Hayward, California. He completed a two year post graduate training program at OMI Family Center; a behavioral health outpatient clinic working with children and adults in San Francisco. Charlie is a results-focused and confident therapist who uses an eclectic style of modalities including cognitive behavioral therapy, family therapy, play-based therapy, trauma-focused therapies, motivational interviewing and other evidenced-based techniques. Charlie has extensive experience working with people with various challenges including trauma and grief, inattention and hyperactivity, substance use, anxiety, depression, identity issues, behavioral problems and many more. Charlie enjoys snowboarding, hiking, biking and spending time with his family.
Dolores Montanez
Licensed Clinical Social Worker (LCSW)
Masters Degree in Social Work (MSW), Colorado License Number: 09925078 Dolores I. Montañez, LCSW has a Master’s degree from the University of Chicago, School of Social Service Administration and Bachelor’s degree from University of Illinois Jane Adams School of Social Work. She utilizes several evidenced base treatment methodologies.  As a Bilingual/ Bicultural Clinician, she focuses on values and beliefs that individuals and families maintain as their strengths.  Cognitive behavioral, Family systems, and solution-focused therapies are utilized with adults and families facing history of trauma, or mental illnesses such as Mood disorders and Anxieties.  Stress management, evidenced based coping strategy, and psychoeducation methods are implemented while treating individuals experiencing life difficult transitions.   She is highly qualified bilingual clinician conducting Forensic Mental health assessments for immigration case purposes.
Deborah Westervelt
Licensed Clinical Social Worker (LCSW )
Master of Social Work (MSW), Colorado License Number: 09923195 Deborah is a licensed clinical social worker. She earned her bachelor’s degree in social work from the University of Tennessee, Chattanooga. She earned her master’s degree in social work from the Brown School of Social Work at Washington University in St. Louis, Missouri. Deborah completed a two- year post graduate program in Marriage and Family Therapy through the Karl Menninger School of Psychiatry and Mental Health Sciences. Deborah is trained in a number of evidence based cognitive behavioral therapies to include DBT, a therapy that especially helps with emotional regulation and skill building. For over 20 years, she has worked with clients of all ages and from many different cultural backgrounds who present with a variety of life’s concerns and challenges. Deborah believes all people have strengths and abilities they can access to work toward creative problem-solving.
Jessica Jimenez
Licensed Social Worker (LSW)
Jessica graduated from Columbia University School of Social Work with her Masters in Social Work with a concentration in Advanced Clinical Practice and Health/Mental Health and Disabilities as her field of practice. Her style is eclectic, humanistic, and relational, and driven by a psychodynamic, cognitive behavioral therapeutic, and a dialectical behavioral informed lens. She has experience working with diverse client populations, including working with individuals at an assisted-living home/residential senior housing facility in New York City where she provided supportive counseling with residents experiencing ongoing loss and aging-related transitions, isolation and loneliness, enhanced needs–such as chronic homelessness, previous struggles with addiction or polysubstance use or abuse, mental illness, physical decline or illness, loss of independence, and trauma. She has also worked as a Case Manager supporting children and adults with intellectual and developmental disabilities—and their families, as they navigated Medicaid waivers and services, advocating for clients, and focusing on a strengths-based approach.

Regulation of Psychotherapists: 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 of the Colorado Department of Regulatory Agencies. The State Board of Marriage and Family Therapist Examiners can be reached at1560 Broadway, Suite 1350 Denver, CO 80202 Phone: 303-894-7800. The regulatory requirements for mental health professionals provide that a 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. A Licensed Psychologist must hold a Doctorate degree in psychology and have one year of post-Doctorial supervision. A Licensed Social Worker must hold a Master’s degree in social work. A Psychologist Candidate, 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 Certified Addiction Counselor I (CAC I) must be a high school graduate, and complete required training hours and 1000 hours of supervised experience. A CAC II must complete additional required training hours and 2000 hours of supervised experience. A CAC III must have a Bachelor’s degree in behavioral health, and complete additional required training hours and 2000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical Master’s degree and meet the CAC III requirements. A Registered Psychotherapist is 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.

Disclosure of Practice Policy: In order to expand the availability of counseling services, the Organization has contracted with Tri-County Health Network to secure counseling services through licensed therapists using teletherapy technology.

Teletherapy is the delivery of counseling services using videoconferencing technology where the therapist and the client are not in the same physical location. The laws that protect the privacy and confidentiality of medical information also apply to teletherapy.

Our therapists use EasyCARE, a HIPAA compliant videoconferencing platform. EasyCARE’s interactive videoconferencing and electronic systems incorporate network and software security protocols to protect the confidentiality of your or your child’s information and audio and visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. EasyCARE’s videoconferencing technology is HIPAA compliant and is encrypted to prevent the unauthorized access to my private medical information.

Please understand that there are risks and consequences with using teletherapy, including, but not limited to, the possibility, despite reasonable efforts on our part, that: the transmission of your information could be disrupted or distorted by technical failures and/or that security protocols can fail, causing a breach of privacy of your confidential medical information. Also understand communication through teletherapy occurs over secure telecommunication lines dedicated for this purpose and that the likelihood of a videoconference being intercepted by unauthorized persons is similar to the potential interception of a phone call.

To help maintain confidentially, you understand that email and text messages are neither secure nor acceptable means of communicating with your therapist and agree that the only electronic communication with your therapist will be the link to the session. Further you agree to inform your therapist if any other person can hear or see any part of you or your child’s session before the session begins. Our therapist will also inform you if any other person can hear or see any part of you or your child’s session. Please note that you may not record your or your child’s therapy session.

Teletherapy based services may not be as complete as face-to-face services. If your therapist believes you or your child would be better served by another form of therapeutic services (e.g. face-to-face services) we will refer you to a professional who can provide such services in your area. Also, note that care and treatment associated with any form of psychotherapy is not an exact science and that we can provide no guarantee as to the result of treatment.
Lastly you have the right to withhold or withdraw your consent to the use of teletherapy during the course of your or your child’s care at any time. Additionally, your therapist has the right to withhold or withdraw their consent for the use of teletherapy during the course of your or your child’s care at any time as well. Withdrawal of consent will not affect any future care, although such care will depend on the availability of alternative resources.

Disclosure Regarding Confidentiality: Generally speaking, information provided by and to a client in a professional relationship with a psychotherapist is legally confidential, and the therapist cannot disclose the information 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 and the HIPAA Notice of Privacy Practices you were provided, as well as other exceptions in Colorado and Federal law. Examples of when your therapist may be required to disclose confidential information include, but are not limited to, the following:

● If you provide any information suggesting a child or vulnerable adult is being abused or neglected. In this case, your therapist is required by law to make a report to law enforcement or an appropriate child or adult welfare agency.

● If you make a threat of imminent physical harm to anyone, including harm to a child, your therapist is required to report this to law enforcement and to the person(s) threatened.

● If there is reason to believe that you are a danger to yourself or that you are gravely disabled and unable to care for yourself, then your therapist is required to initiate a mental health evaluation that could result in you being held against your will for your own safety and well-being.

● If your therapist is presented with a direct court order, then disclosure may be required in the presence of a judge.

If you are a parent or guardian consenting to mental health services on behalf of a minor child, you understand that you may not request access to the minor child’s records in connection with any legal proceeding involving a determination of the best interests of the minor child because the minor child has a right to privileged and confidential communications. You understand our therapists will not produce the minor child’s records in that type of legal proceeding without a valid authorization or court order.
You should be aware that our therapists may need to share protected information with administrative support staff for both clinical and administrative purposes. These staff members have been trained about protecting your privacy and have signed agreements to not release any information without permission.
Lastly there are certain times that our therapists will talk about part of your situation with another therapist. Our therapists regularly consult with other therapists to help in giving high-quality treatment. These clinicians are also required to keep your information private. Your name or identifying information will never be given to them, and they will be told only as much as they need to understand your situation.

Clinical Records: The laws and standards of the therapist profession require that we keep Protected Health Information about you in your Clinical Record. Colorado has a psychotherapist-patient privilege which means mental health professionals cannot be asked about any knowledge gained during the course of therapy without the consent of the person to whom the testimony relates. This privilege extends to treatment records including psychotherapy notes.

Adolescent patients in particular require the privacy protection provided by the psychotherapist-patient privilege due to the sensitive nature of children’s mental health care.

While patients have the right to submit in writing a request to examine and/or receive a copy of the Clinical Record, these are professional records and can be misinterpreted and/or upsetting to untrained readers. If we believe disclosure of records may cause psychological harm to the patient, we may instead provide you with a written summary of the records (C.R. S. 25-1-802 (1) (a). If we refuse your request for access to records, you have a right of review, which we will discuss with you upon request.

Our contracted therapists use an electronic records management system to store, organize and access all Clinical Records. In order to maintain security, we use firewalls, antivirus software, passwords and encryption methods to prevent unauthorized access. In addition, our backups are stored using cloud based backup services. This is to help prevent the loss or damage of records. We maintain the security of these backup systems through HIPAA compliant encryption and passwords and have entered into HIPAA Business Associates Agreement with both the cloud based and electronic records companies. Because of this agreement, the company is obligated by federal law to protect these backups from unauthorized use or disclosure.

Email/Internet/Social Media: We take your privacy very seriously. Therefore, we also take electronic modes of communication and media very seriously. We never conduct a search of a client online. We do not accept friend or contact requests from current or former clients on any social networking site. We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. As we cannot guarantee your privacy and confidentiality in email or text communications, we request that you not email our therapists any therapeutic/clinical information. Please note that any email you send becomes part of the permanent record.

Clinical Emergencies: If you experience an emergency for which you need immediate help, please be aware that we do not provide 24-hour crisis services. If you are experiencing an emergency situation, call 911 or proceed to the nearest hospital emergency room for help. If you are having suicidal thoughts or making plans to harm yourself please call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24-hour hotline support, or call the Center for Mental Health Crisis Line at 970-252-6220. Please use your best judgment in keeping yourself and your child safe.

Contact Information: If you require additional information or have further questions, please contact Tri-County Health Network, 238 East Colorado Ave, Suite 8, PO Box 4178, Telluride, CO 81435, 970-708-7096 (Fax 888-595-3242), or via email at

Client Signature, Acknowledgement, Agreement, Consent:
Your signature below indicates:

• You have read through this document carefully and discussed to your satisfaction any questions you may have about the information it contains.
• You agree to abide by all of the standards, expectations, policies and laws set forth in this document.
• You understand that you may request a signed copy of this document at any time.
• You voluntarily consent to therapy, counseling and/or evaluation services for yourself, or your minor child, by licensed therapists using teletherapy.
• You understand that you have the right to revoke consent at any time.

*use mouse or cursor to sign name

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