Poling Chan, MSW, LCSW

I authorize Poling Chan to provide assessment and psychotherapy for myself/child. I acknowledge having reviewed the office policies including fee structure and cancellation policy. Failure to give 24 hours notice prior to cancellation will result in full payment for the time reserved for me.

NOTICE OF PRIVACY PRACTICES

I acknowledge having received and read the Notice of Privacy Practices.

RELEASE OF INFORMATION

I authorize release of information of any medical information necessary to process EAP or insurance claims. I also give permission for my therapist to exchange information with the source of referral:

I acknowledge being informed of my therapist’s credentials and license information as follow.

Hong Kong Polytechnic University, BSW 1987

Washington University, MSW, 1992

Colorado LCSW License # 992606

Certified EMDR therapist

The practice of both licensed and unlicensed psychotherapists is regulated by the Department of Regulatory Agencies under CRS 12.43.214 (1)(c).  Questions or complaints may be addressed to:

Colorado State Grievance Board
1560 Broadway, Suite 1340
Denver, CO 80202
(303) 894-7760

Under this statute, 12.43.214 (1)(d) CRS,  you are entitled to receive information about the methods of therapy, the techniques used, the duration of therapy (if known), and the fee structure.  You may seek a second opinion from another therapist or may terminate therapy at any time.  In a professional relationship, sexual intimacy is inappropriate and should be reported to the Grievance Board.

12.43.214 (1)(d) CRS states that information provided by a client during therapy sessions is legally confidential in the case of licensed clinical social workers, except as provided in section 12.43.218 and except for certain legal exceptions which will be identified by the licensee should any such situation arise during therapy.