Psychiatry ‐ Student Mental Health & Private Patient Registration 

PROVIDER NAME - Program: Grad. Date:

Patient Information: All Fields are Required Date of Registration:
Patient name
SSN
Sex
DOB
Address
City, State, Zip County:
Home Phone
Mobile
Email
Primary Language
Marital Status
Ethnicity
Race
PCP
Pharmacy Location:
Emergency Contact: Name: Relationship:
Phone:
Guarantor Account: This is Duplicate Information if the patient is over 18 (Guarantor is Patient)
Name
Sex
SSN
DOB
Address
City, State, Zip
Home phone
Work phone
Guarantor Employer: This is required as the patient (over 18) is the Guarantor
Employer
Address
City, State, Zip
Phone
Subscriber Account: This is the Insurance Policy Holder - Required
Subscriber Name DOB:
Coverage Name
(Insurance Carrier)
Insurance ID
Group Number
Address
City, State, Zip
Home Phone
Work Phone
Mobile
Email
Subscriber Account: This is the Insurance Policy Holder – Required (Secondary Insurance)
Subscriber Name
Coverage Name
(Insurance Carrier)
Insurance ID
Group Number
Address
City, State, Zip
Home Phone
Work Phone
Mobile
Email
 
   

 
PATIENT REGISTRATION AND CONSENT FOR TREATMENT 
1. CONSENT FOR TREATMENT. I voluntarily consent to inpatient and/or outpatient care and treatment performed by 
my physician and all other health care providers at University of Colorado School of Medicine health care delivery sites. I also 
consent to routine services, diagnostic procedures, medical treatment, other health care services deemed necessary by the health 
care providers treating me. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and 
treatment may cause injury or even death. I understand that I have a right to consent or to refuse to consent to any proposed surgery, 
procedure or treatment, and to discuss it with my health care provider. I also understand that in the course of my medical 
treatment I may have one or more photographs of my skin or wound(s) taken, to use in monitoring my treatment and guiding 
healthcare provider interventions. I understand that individuals who want to learn about the roles of healthcare providers may observe the 
treatment I receive and I consent to this but I have the right at any time to object to letting such an individual observe and my objection 
will be honored. If this Patient Registration and Consent for Treatment is signed as part of an Emergency Department or 
other outpatient visit, it will continue for any related inpatient admission. I understand that if I am participating in a 
research protocol and have signed the Colorado Multiple Institutional Review Board (COMIRB) consent form, all provisions of this 
Patient Registration and Consent for Treatment shall apply to those tests and services not included within the research 
protocol. 
2. AUTHORIZATION, FOR RELEASE OF INFORMATION. I authorize University of Colorado School of Medicine 
and its health care delivery sites to utilize confidential medical/Surgical or other information contained in my medical record as 
necessary for claims payment, medical management, or quality of care review purposes. I further authorize the release and 
discharge of such confidential, information to my insurance company or other health coverage plan, including government 
payers, as necessary for claims payment, medical management and quality review activities conducted by such company or 
plan, or its designees. This authorization includes the release of an Acquired Immunodeficiency Syndrome (AIDS) diagnosis or 
a positive Human Immunodeficiency Virus (HIV) antibody test result, alcohol and/or drug abuse information, genetic testing, 
congenital disorders, and mental health information. I understand this authorization for release of information can be revoked by 
me in writing at any time, but only with respect to the proposed treatment and not with respect to care and treatment that 
has already been rendered to me. I understand that if I am a participant in a human subject research protocol, my medical 
information may be further released to agencies and individuals identified in the COMIRB Subject Consent Form. 
3. WAIVER OF RESPONSIBILITY FOR PERSONAL VALUABLES.  I understand that the University of Colorado 
School of Medicine or any of its health care delivery sites do not assume any responsibility for the loss or damage to my 
personal property. 
4. PAYMENT AGREEMENT AND ASSIGNMENT. Except as prohibited by any agreement between my insurance company 
and The University of Colorado School of Medicine, University Physicians, Inc. (Faculty Practice Plan) or by state or federal law, I  agree 
to be responsible for my co‐payments, deductibles or other charges for medical services not covered or paid by insurance or other 
third party payers. I authorize The University of Colorado School of Medicine and University Physicians, Inc. to file any claims for 
payment of any portion of the patient bills and assign all rights and benefits to The University of Colorado School of Medicine and 
University Physicians, Inc. as appropriate. I further agree, subject to state or federal law, to pay all costs, attorney fees, expenses and 
interest in the event The University of Colorado School of Medicine and University Physicians, Inc. take action to collect same because 
of my failure to pay in full all incurred charges.  By signing below, I consent to be contacted by regular mail, by email or by 
telephone (including a cell phone number) regarding any matter related to the above referenced account by the creditor, 
its successors or assigns.  This consent includes any updated or additional contact information that I may provide and 
includes contact that employs auto‐dialer technology and/or prerecorded messages. 
 
 

I have read this form, and by signing this form I understand and agree to what it says. 
The consent for treatment shall be effective for (1) year. 
 
 
 

________________________________________________   ____________________________________________ 
Patient Signature             Date                          Patient Print Name 
(Or parent/guardian/other authorized person     
if Patient is a minor, mentally incompetent, or                           _____________________________________________  
physically unable to sign this form)               Witness to signature 
  
__________________________________________________                               ____________________________________ 
 Printed name and relationship to person                      Reason Patient is unable to sign                          

Consent to Treat - English – v.3

Date Last Updated 03/13/2012
 University of Colorado School of Medicine &
University Physicians, Inc.

ACKNOWLEDGMENT OF RECEIPT OF JOINT NOTICE

OF PRIVACY PRACTICES

By signing this document, I acknowledge that I have received a copy of the University of Colorado School of
Medicine and University Physicians, Inc. joint “Notice of Privacy Practices” effective September 23, 2013.

_______________________________________ __________________
Name (Sign) Date

_______________________________________
Name (Print)

For Internal Use Only

Reason Acknowledgment was not obtained: ______________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

______________________________________ __________________
Name (Sign) Date

_______________________________________
Name (Print)
 

Notice of Privacy Practices Acknowledgment- English – v.4

Date Last Updated 09/23/2013
I have not previously Opted in and would like to do so now or:
 School of Medicine
Department of Psychiatry
Student Mental Health
Mail Stop F546
13001 E. 17th Place
Aurora, CO 80045
O 303-724-4716
F 303-724-8859

Student Mental Health Guidelines 
 
1. Initial Appointment:  Please check in with our clinical coordinator for your initial 
appointment.  Her office is located in building 500 on the 2nd floor in the east hallway, 
Reception E2301.    Please arrive at least 15 minutes prior to your appointment to 
complete paperwork.  Please bring your insurance card to the first appointment. 
 
2. Insurance:  If you have the student sponsored plan, your plan covers an unlimited 
number of visits with $0 copay.  If you have outside insurance, please check with your 
plan to verify coverage and benefits.  If Student Mental Health (billed through CU 
Medicine formally University Physicians Inc.) is not in‐network, we will help you find an 
in‐network provider and facilitate your referral.  You will be responsible for any co‐
payments at the time of service.  We accept cash, checks, and credit cards.  Checks 
should be made out to CU Medicine.    
 
3. Missed Appointments:  Please provide at least 24 hours’ notice for cancellation or 
rescheduling of follow‐up appointments.   There will be a $40 No Show Fee charged for 
missed appointments.    You will be responsible for the missed appointment fees – these 
are not covered by insurance.  You can pay directly to the SMH Clinic Coordinator in the 
Reception Area.   Exceptions will be at the discretion of the individual clinician.   

 
4. Rescheduling/Cancellations:  If you need to reschedule your initial intake appointment, 
please call 303‐724‐4716 at least 48 hours prior to the scheduled time.  If you don’t 
attend your intake appointment, you may reschedule, but this will not be done on an 
urgent basis.  If you miss two intake appointments, the Student Mental Health team will 
review your situation prior to rescheduling. 
 
5. Altered Mental Status: If a student presents under the influence of alcohol or drugs at 
the time of their appointment or during walk‐in hours, they will be asked to reschedule 
for another appointment time. In some instances this may result in a transport to the 
emergency department for further assessment based on clinician discretion and reason 
for altered mental status. 

6. Resuming Care with SMH:  If you have been seen previously by a Student Mental Health 
provider, please indicate this when you call to resume care with Student Mental Health.   
 
 7. Changing Providers:  If you wish to change your assigned Student Mental Health 
provider, please first work with your current provider to attempt to resolve and address 
any treatment issues.  If you still have concerns, please notify our clinical coordinator at 
303‐724‐4716.  The Student Mental Health team will review your case. 
 
8. Visit Frequency:  In order to remain a patient with Student Mental Health, you must be 
seen by your clinician at least once every three months.  Otherwise, your file will be 
closed.   
  
9. Prescription Refill Requests:  Please plan for a 72 hour window when requesting 
prescription refills.  You may ask your pharmacy to contact us or you may contact your 
provider directly.  If you choose to contact us directly, please provide the following 
information: 
 spell your last name  
 pharmacy phone number 
 date of birth 
 name of medication 
 dose of medication 

Please keep in mind that Schedule II medications (e.g. stimulants) require a paper script 
and cannot be called in.   
 
10. CPDMP:  If you are prescribed a controlled substance, your prescription information will 
be loaded into the Prescription Drug Monitoring Program and may be queried by 
authorized individuals. 
 
11. Confidentiality:  Information shared during appointments is confidential and will not be 
discussed or exchanged with anyone without your explicit written permission.  
However, there are several situations in which your clinician is legally bound to report to 
the appropriate authorities.  This includes indications of child abuse.  Imminent danger 
to yourself or others may require the clinician to breach confidentiality in order to 
ensure safety.  Please see University of Colorado School of Medicine & CU Medicine 
(University Physicians, Inc.) Notice of Privacy practices for more details.    
 
12. Email Communication: Email communication is at the discretion of the student. Email 
accessed through My Health Connection is confidential.  Email communication sent  
 
 through other services cannot be guaranteed as confidential and is subject to less 
stringent privacy laws. If you are comfortable using email as a form of communication, 
please sign and date below.  
 
13. Off‐Hours Coverage:  During regular business hours (Monday – Friday 8:30am – 5pm), 
you may contact the Student Mental Health Clinic Coordinator at 303‐724‐4716.  She 
will forward your call to the appropriate clinician, and your call will be returned by the 
end of the next business day.  For after‐hours, holiday, and weekend coverage, call 303‐
370‐9127 and ask to speak to Attending.  Identify yourself as an AMC student.  Your call 
will be directed to an on‐call clinician and returned within several hours.   
 
 

Signed: ___________________________________  Date: _______________________ 
 
 
 
I am aware of the email communication policy and the potential risks of emailing with my 
provider. I am comfortable using email as a means of communication with my mental health 
provider. 
 
 
 
Signed: ___________________________________  Date: _______________________ 
 
 
Please print your name:_________________________________________________________________ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Revised 3/2017 
 
 
Rob Rosenthal, Psy.D.
Licensed Psychologist
13001 E 17th Pl, Aurora, CO, 80045
Tel: 303-724-9637

THERAPIST
I, Dr. Rob Rosenthal, have a Doctorate in Clinical Psychology from the University of Denver (2009),
a Master’s in Clinical Psychology from the University of Denver (2007), and a B.A. in English from
Princeton University (1994). I am a licensed clinical psychologist in the state of Colorado; my
license number is 3655. I am an independent practitioner, and, as such, am not legally or
professionally affiliated with any other mental health professional.

YOUR RIGHTS
As a client seeking mental health services, you have certain rights. These include your right to seek a
second opinion from another therapist or your right to terminate this therapy at any time. You are also
entitled to receive information regarding the methods of therapy, techniques used, the duration of
therapy, if known, and the fee structure. Please ask if I do not fully provide you with this information
or if you have any questions.

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 Psychologists Examiners can
be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800. As to the
regulatory requirements applicable to mental health professionals: a Licensed Psychologist must hold
a doctorate degree in psychology and have one year of post-doctoral supervision. A Licensed
Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional
Counselor must hold a masters degree in their profession and have two years of post-masters
supervision. A Licensed Social Worker must hold a masters degree in social work. A Psychologist
Candidate, a 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 1,000 hours of supervised experience. A CAC II must
complete additional required training hours and 2,000 hours of supervised experience. A CAC III
must have a bachelor’s degree in behavioral health, and complete additional required training hours
and 2,000 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 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.

THERAPEUTIC RELATIONSHIP
Your relationship with me is a professional and therapeutic relationship. In order to preserve this
relationship, it is imperative that I not have any other type of relationship with you. Social and/or
business relationships undermine the effectiveness of the therapeutic relationship. Gifts, bartering,
and trading services are not appropriate and should not be shared between us. Additionally, in a
professional relationship, sexual intimacy is never appropriate and should be reported to the Board
that licenses, registers, or certifies the licensee, registrant or certificate holder.

PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep treatment records. You are entitled to
receive a copy of your records, or I can prepare a summary for you instead. Because these are
professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to
see your records, I recommend that you review them in my presence so that we can discuss the
contents.

Any person who alleges that a mental professional has violated the licensing laws related to the
maintenance of records of a client eighteen 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 this. 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. Client records may not be maintained after seven years following the end of
treatment.

CONFIDENTIALITY
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. The Mental Health Practice Act (CRS 12-43-
101, et seq.) is available at: http://www.dora.state.co.us/mentalhealth/Statute.pdf. For example, as a
mental health professional, I am required to report suspected child abuse to authorities. Also, if I
believe that a client is threatening serious bodily harm to another, I am required to take protective
actions. These actions may include notifying the potential victim, contacting the police, or seeking
hospitalization for the client. Furthermore, if a client threatens to harm himself/herself, I may be
obligated to seek hospitalization for him/her or to contact family members or others who can help
provide protection. In most legal proceedings, you have the right to prevent me from providing any
information about your treatment; yet, in some proceedings involving child custody and those in
which your emotional condition is an important issue, a judge may order my testimony if he/she
determines that the issues demand it. If you request that I share information with third parties, I
cannot guarantee the confidentiality of information that leaves this office. Additionally, under the
USA Patriot Act, I am required to report threats to national security. These situations have rarely
occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with
you before taking any action. If a legal exception arises during therapy, if feasible, you will be
informed accordingly.

While this written summary of exceptions to confidentiality should prove helpful in informing you
about potential problems, it is important that we discuss any questions or concerns that you may have
at our next meeting.

AGREEMENT

Your signature below indicates you have read the preceding information, it has also been provided
verbally, and that you understand your rights as a client. Your signature below indicates that you
agree to abide by its terms during our professional relationship.

______________________ _____________________________ ___________________

Client Signature Printed Client Name Date