Disclosure Statement

Shoshana Ort, LCSW

Version 2026-07-11.4

Treatment Unit. This Disclosure Statement is entered into as part of the Treatment Unit consisting of Client One and Client Two. Each member signs an identical copy of this Disclosure Statement.

1 · Credentials and Regulation of Psychotherapists

Shoshana Ort is a Licensed Clinical Social Worker in the State of Colorado (License Number CSW.09926088), holds a Master of Social Work from Long Island University, and is working towards certification as an Emotionally Focused Couples Therapist by the International Center of Excellence for Emotionally Focused Therapy (ICEEFT).

The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Department of Regulatory Agencies. The regulatory board can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.

A Licensed Clinical Social Worker must hold a master's or doctorate degree from a graduate school of social work, have practiced as a social worker for at least two years, and pass an examination in social work.

2 · Client Rights and Important Information

You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy (if known), and my fee. Please ask if you would like to receive this information.

You can seek a second opinion from another therapist or terminate therapy at any time.

In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs it should be reported to the board that licenses, certifies, or registers the therapist.

Under Colorado law, C.R.S. § 14-10-123.8, custodial 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 from me, I may provide you with a treatment summary, in compliance with Colorado law.

My records regarding the treatment of adults will be kept for seven (7) years after treatment ends or following our last session, but may not be kept after seven (7) years. My records for treatment of minors will be kept for seven (7) years commencing on the last date of treatment or when the minor reaches eighteen (18) years of age, whichever comes later, but in no event am I required to keep these records for longer than twelve (12) years.

3 · Policies Specific to My Practice

Divorce and Custody Litigation: If you are involved in divorce or custody litigation it is not my role as a therapist to make recommendations to the court concerning custody or parenting issues. By signing this Disclosure Statement, you agree not to subpoena me to court for testimony or for disclosure of treatment information in such litigation and you agree not to request that I write any reports to the court or to your attorney making recommendations concerning custody. The court can appoint professionals who have no prior relationship with family members to conduct an investigation or evaluation and to make recommendations to the court concerning parental responsibilities or parenting time in the best interests of the family's children.

Consultation: I sometimes consult with other professionals regarding my therapy clients as this is a best practice in the field of psychotherapy. Any professionals with whom I consult will be held to the same confidentiality requirements as I am. Your signature on this Disclosure Statement gives me permission to consult with other professionals about your case at my sole discretion.

Payment and Fees: For the purposes of calculating the fee for a session, there is a minimum charge of 50 minutes for any session, regardless of its actual length.

For any session that starts after 10:00 AM and ends before 5:00 PM on non-holiday Mondays, Tuesdays, Wednesdays, Thursdays or Fridays, the fee for a 50 minute session is $160.00, the fee for a 75 minute session is $240.00, and the fee for additional 10 minute increments (rounded up to the next 10 minutes) is $30.00.

For any sessions that occur on Saturdays, Sundays or holidays, or that start before 10:00 AM or end after 5:00 PM, the fee for a 50 minute session is $180.00, the fee for a 75 minute session is $270.00, and the fee for additional 10 minute increments (rounded up to the next 10 minutes) is $35.00.

For any telephone calls, except for telephone calls related only to scheduling of appointments, there is a fee of $35.00 per 10 minutes (rounded up to the next 10 minutes), which will be charged to your credit card on file after the call is complete.

Payment is due at each session unless other arrangements have been made. The fees outlined above are subject to change at any time, and will likely go up every January 1.

Overdue Payment: If your account is more than 30 days overdue and suitable arrangements have not been agreed to, I have the option of using legal means to secure payment, including collection agencies or small claims court, and you agree that I may disclose your personal information as needed for the purposes of collecting outstanding balances. You will be responsible for any and all legal or collection costs I incur in my attempts to collect any outstanding balance.

Third Party Payments (by Clergy or other family members): When clergy or other family members offer to pay, in full or in part, for services you receive at Colorado Center for Couples and Families, you may be asked to make a copayment at the time of each session. If this third party does not pay for any reason, you remain personally responsible for the full fee.

Cancellation, No-Shows, and Credit Card: To cancel or reschedule a session without penalty you must provide at least the following notice (Required Notice): 2 days (48 hours) for a session that is scheduled for 75 minutes or less; 7 days (168 hours) for sessions scheduled for more than 75 minutes; 7 days (168 hours) for any session scheduled on a day in which you have scheduled more than one session on that day (e.g. one session for each individual in a couple scheduled in the same day).

A "Late Cancellation Charge", calculated as the greater of $240 or the full fee for the scheduled session, will be charged for any session for which you do not show up within 15 minutes of the scheduled start of the session and/or for any session which you cancel or reschedule with less than the Required Notice, such notice to be provided by leaving a voice message at 303-682-6900, by sending an email to shoshana@coloradocouples.com, or by cancelling the session using our on-line scheduling system. This cancellation policy is subject to change at any time by providing written notice of the new policy. (Please note that if a couple or family session is scheduled, we will not start the session until ALL individuals scheduled for that session show up. You cannot substitute an individual session for a couples or family session).

Telehealth Services: Sessions may be conducted via secure video technology. By participating in a telehealth session, you acknowledge that despite reasonable security measures, electronic communication carries inherent risks to confidentiality that do not exist with in-person sessions. You are responsible for ensuring you are in a private location during telehealth sessions. Telehealth may not be appropriate for all clinical situations, and I reserve the right to require in-person sessions when clinically indicated.

Court Appearances and Reports: Any court appearances (including any time I spend preparing for a court appearance and travel and waiting time associated with a court appearance) as well as any time I spend writing or preparing reports for you or any third party regarding your therapy, will be billed at $600 per hour (rounded up to the next hour) against a retainer of not less than $6,000 payable to Colorado Center for Couples and Families by you in advance of my beginning any work.

4 · Secrets Policy

This written policy is intended to inform you that when I agree to treat a couple or a family, I consider that couple or family (the Treatment Unit) to be the client. For example, if there is a request for the treatment records of the couple or the family, I will seek the authorization of all members of the Treatment Unit before I release confidential information to third parties. Also, if my records are subpoenaed, I will assert the psychotherapist-patient privilege on behalf of the Treatment Unit.

During the course of my work with a couple or a family, I may see a smaller part of the Treatment Unit (e.g., an individual, a parent/child, two siblings, etc.) for one or more sessions, and I may communicate with individual members of the Treatment Unit via phone, email, etc. By signing this Disclosure Statement below, you agree that these sessions and communications are conducted as a part of the work that I am doing with the Treatment Unit; that based solely on my judgement, I may determine a need to share with other members of the Treatment Unit the information disclosed to me in these sessions and communications; and that I may use my best judgment to determine whether, when, in what manner, and to what extent I will disclose such information to other members of the Treatment Unit.

This Secrets Policy is intended to allow me to continue to treat the Treatment Unit by preventing, to the extent possible, a conflict of interest to arise where an individual's interests may not be consistent with the interests of the Treatment Unit (for example, information learned in the course of an individual session may be relevant or even essential to the proper treatment of the couple or the family. If I am not free to exercise my clinical judgment regarding the need to bring this information to the family or the couple during their therapy, I might be placed in a situation where I will have to terminate treatment of the couple or the family. This policy is intended to reduce the risk that such a termination might be necessary). Because you are explicitly agreeing that I may share information with other members of the Treatment Unit, if you desire to talk about matters that you do not want shared with other members of the Treatment Unit, you are encouraged to consult with an individual therapist.

5 · Confidentiality

Generally speaking, the information provided by you and/or provided to you during therapy sessions is legally confidential and cannot be released without your consent. There are exceptions to this confidentiality, some of which are listed in C.R.S. 12-245-220 as well as other exceptions in Colorado and Federal law. If a legal exception arises during therapy, if feasible, you will be informed accordingly. The Mental Health Practice Act (C.R.S. 12-245-101, et seq.) is available at: https://dpo.colorado.gov/ProfessionalCounselor.

Some of the circumstances where disclosure is required by law are as follows:

• If there is a suspicion of the abuse or neglect of a child, or the viewing of child pornography, I am required to file a report to appropriate protective and/or law enforcement agencies;
• I am required to report to law enforcement any elder abuse of a senior 70 years of age or older when I have probable cause to believe that abuse has occurred or is occurring;
• When you present/threaten imminent physical harm to another person I have a legal duty to warn those threatened, and to contact law enforcement;
• When you are actively suicidal or threaten significant bodily harm to yourself, or when I believe that you are gravely disabled as a result of a mental disorder, I must obtain help from others and initiate a mental health evaluation;
• I am required to report to federal officials any suspected threat to national security;
• I may be required by Court Order to disclose treatment information; and
• Disclosure may be required pursuant to legal proceedings. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the therapy records and/or testimony by your therapist. If you are on probation/parole, it may be legally required that I share information with individuals appointed by the court.

6 · Audio and Video Recording of Sessions

This consent is separate from the rest of this Disclosure Statement and is entirely voluntary. You may decline and still receive therapy, and you may withdraw it at any time in writing without any effect on your treatment.

In order to provide the best possible therapy treatment, it is common for therapists to record video of therapy sessions. The purpose of recording therapy sessions is to enhance the effectiveness of therapy by providing me with a way to review your therapy sessions. I also consult regularly with other professionals (all of whom are bound by confidentiality laws) concerning our respective clients, and this consultation sometimes includes reviewing recorded portions of therapy sessions.

By consenting below you consent to allow your therapy sessions to be recorded by audio and video; you give me permission to, at my sole discretion, review the recordings with my professional colleagues; you acknowledge your understanding that you may withdraw this consent for your sessions to be recorded at any time by providing written notice to me; you acknowledge your understanding that copies of audio/video recordings are not kept as part of the clinical record; and you acknowledge that you have had an opportunity to ask questions and that your questions have been answered satisfactorily.

Execution

Counterparts/Execution. This Disclosure Statement may be executed in counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same instrument. Signature pages may be executed via "wet" signature or electronic mark and the executed signature pages may be delivered using pdf or similar file type transmitted via electronic mail, cloud based server, e-signature technology or other similar electronic means.

By signing below you acknowledge that you have read, understand, and agree to the provisions contained in this Disclosure Statement; that you have received a copy of this Disclosure Statement; that the information has been presented to you; that you understand the disclosures that have been made to you; that you enter therapy as a member of the Treatment Unit that includes all the members of the Treatment Unit named at the top of this Disclosure Statement; and that you acknowledge your understanding that results of therapy cannot be guaranteed and that no warranty is given, implied or expressed.