| Licensed Psychologist Full Name: Holly K. O'Donnell, PhD
Credentialed Address: 1775 Aurora Court, MS A140, Aurora CO 80045
Phone Number: 303-724-0377
COLORADO MANDATORY DISCLOSURE STATEMENT
This disclosure statement of practice and office policies will help you clearly understand your rights and responsibilities as a client. Please read carefully. Your signature on the last page of this document represents an agreement between us. This disclosure statement contains my policies and procedures and is HIPAA compliant. No medical or psychotherapeutic information, or any other information related to your privacy, will be revealed without your permission unless mandated by Colorado law and Federal Regulations (42 C.F.R. Part 2 and Title 25, Article 4, Part 14 and Title 25, Article 1, Part 1, CRS and the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 142, 160, 162 and 164).
Education and Credentials:
• Master's Degree: University of Colorado Denver, 2016 • Required 58 credit hours of coursework
• Doctorate Degree: University of Colorado Denver, 2020 • Required 100 credit hours of coursework
• Internship: Harvard Medical School/Boston Children's Hospital, 2020
• Fellowship: University of Colorado Barbara Davis Center for Diabetes, 2022 • Required 1,500 hours
• Psychologist License # PSYC.0005779
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 Colorado State Board of Psychologist 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 with a major in psychology, or the equivalent to that major as determined by the board and have at least one year of postdoctoral experience practicing psychology under supervision.
You are entitled, to receive information from your therapist about the methods of therapy, the techniques used, the duration of your therapy, if known, and the fee structure. You can seek a second opinion from another therapist or terminate therapy at any time.
Your records may not be maintained after seven years pursuant to section 12-245-226 (1) (a) (II) (A)
Limitation of Services:
I do not offer 24-hour care. If you need after-hours care, I will assist you in finding the proper resources. If you are experiencing a mental health emergency, call Rocky Mountain Crisis Partners (1-844-493-8255) or 911 immediately. You can also contact the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), Metro Crisis Services at 1-888-885- 1222, or go to your nearest emergency room. If you must seek after hour's treatment from any counseling agency or center or hospital, you understand that you will be solely responsible for any fees due. If you leave a voicemail on the phone number provided, I will return your call by the end of the next business day, excluding holidays and weekends.
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.
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 12-245-220 of the Colorado Revised Statutes and the Notice of Privacy Rights you were provided as well as other exceptions in Colorado and Federal law. For example, mental health professionals are required to report child abuse to authorities.
Your signature indicates an informed consent to counseling and agreement to the following:
• I have read the Disclosure Statement & Policies and understand it.
• I have had the opportunity to ask questions and to be provided further explanation pertaining to the Disclosure Statement &Policies.
• I agree to follow the terms, policies, and responsibilities in the Disclosure Statement & Policies.
• I have read the preceding information, it has also been provided verbally, and I understand my rights as a client or as the client's responsible party.
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