This is a private practice providing psychotherapy and evaluation services. This is not a clinic, and I do not
provide emergency services.
       Linda L. Thede P.C. d/b/a
       Thede Family Center for Autism and Neurodevelopmental Disorders
       805 S. Cascade Avenue
       Colorado Springs, CO  80903
       Tele: 719/473-9200             Fax: 719/473-9203
       Website: http://www.heartforlistening.com
       E-mail: DrThede@aol.com

       Dr Thede is licensed in the State of Colorado as both a Psychologist (License #0004148) and a Professional
Counselor (License #0005202).                                        

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 regulatory boards can be reached at 1560 Broadway,
Suite 1350, Denver, Colorado 80202, (303) 894-7800.  The regulatory requirements for mental health
professionals provide that a Licensed Professional Counselor must hold a masters degree in their profession
and have two years of post-graduate supervision, a Licensed Psychologist must hold a doctorate degree in
psychology and have one year of post-doctorial supervision, 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 Registered Psychotherapist is 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.        You are entitled to receive information about my methods of therapy and fees upon request.
       b.        You can seek a second opinion from another organization or terminate therapy at any time.
       c.        Sexual intimacy is strictly prohibited between a therapist and a client.
       d.        The information you provide to me is confidential, but there are several exceptions to confidentiality:
               (1) I am required to report any incident involving the possible abuse or neglect of a child or elderly
person to the Department of Human Services (DHS) for their follow-up
               (2) If you threaten to harm someone, I must report this to law enforcement and to the person(s) being
threatened so they can take proper precautions for their own safety
               (3) If you give me any indication that you may harm yourself or willfully engage in certain risky
behaviors that may endanger you or others, I will share this information with your parents if you are under the
age of 21, and I will initiate further evaluation of you at a medical treatment facility which may or may not
result in hospitalization regardless of your age
               (4) I am required to report to federal authorities any suspected threat to national security
               (5) I may be required by Court Order to disclose treatment information
               (6) If you participate in a workshop, seminar, or group provided by me, confidentiality is limited due to
involvement of other nonprofessional participants
               (7) Your insurance provider(s) may request information regarding your diagnoses and treatment
       e.        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 can provide you with a treatment summary, in compliance with
Colorado law and HIPAA Standards.

               I will bill your insurance provider if you are insured by Medicare (Part B), Colorado Medicaid, CHP+,
Aetna, or Tricare in order to receive reimbursement for my behavioral health services, but I cannot guarantee
their coverage of services. You will be responsible for payment of any uncovered services, deductibles,
coinsurance, or copays. If you are covered by any insurance provider other than those listed above, you will be
required to pay me my full rate out of pocket at the time of service. I can provide you with a detailed receipt
(superbill) upon request so you can submit a claim to your insurance provider on your own behalf for possible
reimbursement. You are responsible for making sure that I have up-to-date contact information for you and up-
to-date information regarding the status of your insurance coverage. You will be removed from my appointment
calendar if you fail to show up for a scheduled appointment without calling to cancel  and reschedule. By signing
below, you are granting me permission to exchange necessary information with your insurance carrier and
their agent.

If you are involved in divorce or custody litigation, I will not make recommendations to the court concerning
custody or parenting issues.  By signing this Disclosure Statement, you agree not to subpoena me for testimony
or for disclosure of treatment information in such litigation; and you agree not to request that I write any
reports to the court or to your attorney, making recommendations concerning custody.  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 family’s children. If the client is a minor child and parents are separated or divorced, you agree
to provide me with documentation from the court regarding custodial arrangements and guardianship matters.

       I have read the preceding information, and it has been presented to me verbally if requested.  I understand
the disclosures that have been made to me and acknowledge that I have received a copy of this Disclosure
Statement if requested. (Parent or legal guardian must sign if client is a child under the age of 12 years.) I
understand that there are limits to confidentiality as outlined above, and I may ask for more information or
explanation of those limits at any time. I understand that Dr. Thede provides evaluations as part of a team in
collaboration with her Business Associates at Whole Kids Co., PLLC, and my signature grants her permission to
consult with them as needed in order to provide me with the best level of care.

Print Client’s Name                                                 Client’s Signature (if age 12 or over)         Date                

Parent’s Name                                                           Parent’s Signature                                          Date
                                                                                       (if client is age 21 or under)