Professional Documents
Culture Documents
My name is Carol Kryder and I have been a licensed mental health professional since 1990,
practicing in four different states. I have worked with all ages, from small children to elderly in
both hospital and outpatient settings. My theoretical orientation is solution-focused, cognitive
behavioral therapy. I am a nationally certified addictions counselor as well as Board Certified
and a Diplomate of the American Psychotherapy Association.
Trained as a family therapist, with a masters degree in Clinical Psychology, I will facilitate the
development of therapeutic goals within the context of your significant relationships. I see my
role as one of guiding you along the road of self-discovery toward the best solution for your
unique situation. My belief is that therapy must address emotional, physical and spiritual
elements. In my role as your coach, non-productive behaviors and attitudes will be challenged
and I may suggest coping skills to manage symptoms, but the final decision is always up to
you.
Our work will include setting measurable goals at the first session; homework every session;
with frequent evaluation to determine if goals are being reached. Clients are encouraged
to actively participate in therapy and take responsibility for their goals; changing them
as necessary. Because trust is essential in completing this process, please feel free and
encouraged to give me any feedback on our sessions. My goal is to create a safe place for
you to explore feelings.
Memberships:
American Psychotherapy Association- Board Certified, Diplomate, Fellow in Counseling
National Association of Alcohol and Drug Counselors- Substance Abuse Professional
Licenses:
California, Marriage and Family Therapist - 1990 # MFC 25628
Colorado Licensed Professional Counselor - 2002 # 3040
____________________________________________________ ________________
Name Date
5525 Erindale Drive, Suite 122
Colorado Springs, CO 80918
Office: 719-266-0724
CLENTNAME____________________DATE_____________ BIRTHDATE___________AGE______
ADDRESS______________________CITY___________________STATE_________ZIP_________
SOC. SEC. # ________________ MARITAL STATUS: S M W D SEX: M F RACE: __________
HOME #: ___________________ WORK #: _________________ OCCUPATION _______________
EMAIL: _____________________________________ EMPLOYER: _________________________
REFERRED BY:___________________________________________________________________
INSURANCE: (primary)____________________ (secondary)________________________________
Family Health History: Please check any boxes that apply to you or your relatives
(parents, children, aunts/uncles, grandparents) and indicate how they are related.
N/A Self Fam N/A Self Fam
Yes No
□ □ Are you taking any medication? List all types and duration ____________________________
__________________________________________________________________________
□ □ Do you have health problems? List, including duration _______________________________
__________________________________________________________________________
□ □ Have you had medical problems in the past? (Problems like surgeries, ulcers, thyroid, etc.)__
__________________________________________________________________________
□ □ Have you ever been on medicine for your nerves? Specify names and dates used:_________
__________________________________________________________________________
□ □ Have you ever been admitted to a psychiatric hospital? Specify name and dates:__________
__________________________________________________________________________
□ □ Have you ever been in psychotherapy before? Explain - therapist, dates and reason:_______
__________________________________________________________________________
□ □ Any past or present legal issues?________________________________________________
__________________________________________________________________________
Women only
Yes No
□ □ Is it possible that you are pregnant?
Number of pregnancies_______ Number of abortions ______ Number of live births ________
□ □ Do you have severe premenstrual mood change?
5525 Erindale Drive, Suite 122
Colorado Springs, CO 80918
Office: 719-266-0724
PAYMENT CONTRACT
1 understand that I will be held responsible for payment for the services I will be
receiving from Carol Kryder, MA, LPC, and that accounts are payable at the time
services are rendered.
If my insurance does not pay for services, I will be responsible for payment according
to the following fee schedule:
ALL DOT SUBSTANCE ABUSE EVALUATIONS ARE CHARGED A FLAT $500 FEE FOR
THE ASSESSMENT, LETTERS TO THE APPROPRIATE ENTITIES, AND A FOLLOW-UP
VISIT AFTER RECOMMENDATIONS ARE COMPLETED. YOU ARE RESPONSIBLE FOR
PAYMENT OF ANY TREATMENT REQUIRED.
I understand that Carol Kryder, MA, LPC will bill my insurance, and I authorize her to bill
and receive payment from my insurance company. Furthermore, I assign any benefits due
from insurance to be paid directly to carol Kryder, MA, LPC. However, since payment Is not
guaranteed, I agree to be responsible for charges denied by my insurance company.
I have read and understand the Payment Contract and agree to abide by it as outlined above
_________________________________ ________
Witness Date
5525 Erindale Drive, Suite 122
Colorado Springs, CO 80918
Office: 719-266-0724
• You have a right to a confidential relationship’ with me. The only legal
exceptions to this are mandated reportable situations, such as “threat of serious
harm to self or others” OR “child abuse, elder abuse, suicide, or grave disability.”
You will always be informed if I decide to make such a report.
• You will receive the following information: My name; business address and
phone number; my degrees, licenses, other credentials and areas of expertise.
• You will receive information about the methods of therapy, techniques used, and
duration of therapy. You may terminate therapy at any time for any reason.
• Sexual intimacy is never appropriate in therapy and is also illegal.
• Payment of fees is expected as outlined in the Fee Agreement. Co-pays are due
at the time of service.
• Licensed psychotherapists are regulated by the Department of Regulatory
Agencies. You may contact them at: 1560 Broadway, Suite 1350, Denver, CO
80202- Telephone: 303-894-7766.
• Insurance companies will be billed by this office, but if payment is not collected,
it is the client’s responsibility to pay for any services rendered. All co-pays and
deductibles are the client’s responsibility and due at each session.
• Therapy sessions are 45 minutes in length.
• Cancellation of appointments must be made 24 hours in advance. Please notify
me as soon as possible in case of illness or other emergency. I reserve the right
to charge $30 for missed sessions or late cancellations.
• You may reach me at 719-660-8844 - voice mail 719-266-0724
• or by email at: ckryderlpc@msn.com
Your health information is private. Keeping your health information private is one of our most
important responsibilities and we take it seriously. The law says: We must keep your health
information ‘from others who do not need to know it. You may ask that we not share certain health
information.
Your private health information may be used by the health care providers who provide your care.
When appropriate we may’ share information about you for coordination of care. We may also use
your information to contact you.
You may see your health information unless it is the private notes taken by your therapist You may
ask for and receive a copy. You will be charged for copying costs. lf you think some information is
wrong, you may ask in writing that it be changed or new information added to your record. You may
ask for a list of places this information has been sent and request that the corrected information be
sent to those places, unless it was sent for treatment, payment, quality review, or to make sure we
are following privacy laws.
You may be asked to sign an authorization form allowing your information to go somewhere else.
The authorization form tells us what, where and to whom the information must be sent. You can
cancel or limit the amount of information sent at any time by letting us know in writing. Typically. the
authorization is good for six (6) months. In Colorado. anyone over the age of 15 is able to consent to
treatment, and confidentiality will be held on behalf of that person. This means parents and others will
not be informed about treatment unless we receive written approval.
Your health information may be released without your authorization in the following cases: 1) payment
2) child or elder abuse 3) danger to self’ or others 4) grave disability 5) court order or subpoena 6)
if you commit a crime on the premises 7) out of state offenders. If you want to know to whom your
information has been released. you may request that information at any time.
Complaints regarding privacy may be filed with Carol Kryder, MA. LPC or you may contact the
Federal Government by calling the Office for Civil Rights at (800) 638-1019.
___________________________________________________ _______________
Signature of Client, Parent or Guardian Date
5525 Erindale Drive, Suite 122
Colorado Springs, CO 80918
Office: 719-266-0724
The Privacy Rule generally requires healthcare providers to take reasonable steps
to limit the use or disclosure of, and requests for PHI to the minimum necessary to
accomplish the intended purpose. These provisions do not apply to uses or disclosures
made pursuant to an authorization requested by the individual. Healthcare providers
must keep a record of all PHI disclosures in the chart notes.
Note: Uses and disclosures of PHI may be permitted without prior consent in an
emergency.