Disclosure Statement

Therapist Name: Yolande D. Schöller
License: CSW.09930392
Business Name: Soothing Dialogues, LLC
Web Address: www.soothingdialogues.com
Email Address: info@soothingdialogues.com

Degrees

Master of Social Work, Southern Illinois University Edwardsville, 2020
Master of Science, Social Sciences, University of Amsterdam, 2015
Bachelor of Science, Interdisciplinary Social Sciences, University of Amsterdam, 2013

Professional Experience
I have completed the state-mandated two years of post-masters supervision and am fully licensed to practice psychotherapy independently as a Licensed Clinical Social Worker in Colorado. I have clinical experience with individual, couples, family, and group therapy for the young adult up to geriatric population suffering from a range of Severe Mental Illness and/or dual diagnosis to mild mental issues, in settings varying from community mental health to the private sector, with both inpatient and outpatient treatment programs.

Regulation of Psychotherapists
The practice of licensed or registered persons in the field of psychotherapy is regulated by the Colorado Department of Regulatory Agencies (DORA) through the Mental Health Licensing Section of the Division of Professions and Occupations. The Colorado Board of Social Work Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.

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 (LAC) 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 Psychologist Candidate, a Clinical Social Worker Candidate (LSW), a Marriage and Family Therapist Candidate (MFT), and a Licensed Professional Counselor Candidate (LPCC) must hold the necessary licensing degree and be in the process of completing the required supervision for licensure.
A Licensed Clinical Social Worker (LCSW) 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 Licensed Marriage and Family Therapist (LMFT) 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 (LPC) 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.

Client Rights

You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy (if I am able to determine that), 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.
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 several exceptions to confidentiality which include:

I am required to report any suspected incident of child abuse or neglect to law enforcement;

I am required to report any threat of imminent physical harm by a client to law enforcement and to the person(s) threatened;

I am required to initiate a mental health evaluation of a client who is imminently dangerous to self or to others, or who is gravely disabled, as a result of a mental disorder;

I am required to report any suspected threat to national security to federal officials;

I am required to report abuse of an elder, who is 70 years of age or older, and also abuse of an at-risk adult with an Intellectual Developmental Disability (IDD), which I believe has probably occurred, including institutional neglect, physical injury, financial exploitation, or unreasonable restraint;

I may be required by Court Order to disclose treatment information.
When I am concerned about a client’s safety, it is my policy to request a Welfare Check through local law enforcement. In doing so, I may disclose to law enforcement officers information concerning my concerns. By signing this Disclosure Statement and agreeing to treat with me, you consent to this practice, if it should become necessary.
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 from me, I may provide you with a treatment summary, in compliance with Colorado law and HIPAA Standards.
I agree not to record our sessions (audio or video) without your written consent; and you agree not to tape record a session or a conversation with me without my written consent.

Crisis/Emergency
Soothing Dialogues, LLC is not able to handle 24-hour contact and/or emergencies. Any emergency situation that you experience should be directed to the appropriate emergency personnel such as the services provided by calling 911, the police, the fire department, a hospital, or your county mental health department.

Fee Information
My standard fee is $150.00 for a 50-minute virtual (telehealth) psychotherapy session. I charge $75.00 for a mental health consult for Gaudiya Vaishnavas. Payment through Zelle is due within 24 hours after the service rendered. Follow-up appointments will be canceled if previous service has not been paid.

Missed Appointments and Cancellations
Please cancel and reschedule your appointment no later than 24 hours in advance. Canceling and rescheduling appointments can be done through email or phone (text message or voicemail). If you show up late for an appointment we may not have the full 50 minutes for our session but you are nevertheless due the full fee. If you miss the appointment and did not cancel 24 hours in advance, you may be charged 50% of the full fee.

Contact Outside of Sessions
I do not offer brief consults, via phone or email, outside of scheduled appointments. Email and voicemail are not monitored 24/7 and I cannot guarantee an answer within a certain amount of time. I reserve the right to decide whether your communication can be addressed through email or if I deem it more clinically appropriate to save the topic for our next scheduled session.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Divorce, Custody Litigation and Other Court Proceedings
I will not voluntarily represent any client in any litigation of any kind, including expert witness or witness of fact, divorce cases, child custody issues, criminal cases, or any other type of court proceeding. By signing this document, you agree not to subpoena me to court for testimony or for disclosure of treatment information; and you agree not to request that I write any reports to the court or to your attorney, making recommendations concerning custody issues or parenting time. 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 children. I cannot fulfill that role. Due to the preparation time required for court involvement and the potential for missed counseling income in my private practice, the charge for any court appearances, including preparation and transportation, is $150.00 per hour.

Maintenance of Records
Any person who alleges that a mental health professional has violated the licensing laws related to the maintenance of records of a client 18 years of age or older, must file a complaint or other notice with the licensing board within seven years after the person discovered or reasonably should have discovered the violation. Pursuant to law, this practice will maintain records for a period of seven years commencing on the date of termination of services or on the date of last contact with the client, whichever is later. When the client is a child, the records must be retained for a period of 7 years commencing either upon the last day of treatment or when the child reaches 18 years of age, whichever comes later, but in no event, shall records be kept for more than 12 years.

Termination of the Clinical Relationship
I will choose to terminate the clinical relationship if it becomes reasonably clear that you no longer need the service, are not likely to benefit from the service, or are being harmed by continued service. Termination against your wishes does not constitute abandonment. I may choose cessation of services if I determine we are not a good therapeutic fit, if what you are going through requires more training than I currently possess, if you require specialized support or if we are not able to form a therapeutically effective relationship. If you chose not to schedule with me for longer than 30 sequential days, you are agreeing that you are no longer using me as a primary care therapist. Any attempt to return to the therapeutic relationship is contingent on my practice having the space to accept you back. If I am full, I will not be able to reenter the therapeutic relationship at that time. If we do begin meeting again you must sign a new disclosure statement and agree to the current fee schedule of the practice.

Informed Consent for Telehealth
By signing this Disclosure Statement, you consent to participate in Telehealth. Telehealth refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of Telehealth is that the client and clinician can engage in services without being in the same physical location.

Confidentiality
Because Telehealth sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. On my end I will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation. I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of our Telehealth. However, the nature of electronic communications technologies is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. I will use HIPAA-secure platforms to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for Telehealth sessions and having passwords to protect the device you use for Telehealth). The extent of confidentiality and the exceptions to confidentiality that I outlined previously in this Disclosure Statement apply in Telehealth. The Telehealth sessions shall not be recorded in any way.

Crisis Management and Intervention
Usually, I will not engage in Telehealth with clients who are currently in a crisis situation requiring high levels of support and intervention. I do 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. By signing this Disclosure Statement, you give me consent to contact your emergency contact in case of an emergency. If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call me back; instead, call 911 or go to your nearest emergency room. If you are 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 Telehealth services are not appropriate, and a higher level of care is required. I will let you know if I decide that Telehealth is no longer the most appropriate form of treatment for you.

Notices of Privacy Practices
By signing this disclosure, you acknowledge receipt of the Notices of Privacy Practices for your review.

Informed Consent for Treatment
I have read this Disclosure Statement, understand the disclosures that have been made, and acknowledge that a copy of it has been provided to me via this webpage. Acknowledging and agreeing to this Disclosure Statement serves as a digital signature.