These files are for Individual and Group Mentoring Courses. Please find, read, and download the files that pertain to you personally.
1. Please be aware that I, Kent S. Rosengren, Psy.D., am a licensed clinical psychologist in the State of Colorado. By law I am required to have anyone I work with, even in a strict mentor/mentee relationship, sign a HIPAA form and provide them with a disclosure statement. All this withstanding, I inform everyone that his/her participation in the Body Based Mindfulness Mentoring Course is for educational purposes only, and does not in any way constitute a therapist/client relationship between myself and the participant. The participant must agree to and understand this limited relationship and a signature will be required on the course registration page.
2. Please understand that there can be no guarantees made that your participation in this class, along with any personal information shared, will be kept confidential by other class members. Principles of confidentiality and privilege do not apply within the context of an online group mentoring class / course.
3. At times, we may discuss topics that might trigger unpleasant memories and/or reactions. You are free at any time to decline to participate in any or all of any possible class activities. Please monitor and stay aware of your own mental and emotional wellbeing.
4. Even while I am teaching an online class, it must be understood that I am a part of a profession required by law to report possible child abuse or neglect if I have “reasonable cause to know or suspect that a child has been subjected to abuse or neglect or who has observed the child being subjected to circumstances or conditions that would reasonably result in abuse or neglect”. If this is the case, I am required to “immediately upon receiving such information report or cause a report to be made of such fact to the county department, the local law enforcement agency, or through the child abuse reporting hotline system as set forth in section 26-5-111, C.R.S”
5. Each class will be recorded and students that are not able to attend class may receive access to the missed class recording. Due to the recording of each class, each student will be required to sign a visual/audio release.
6. If you desire to contact me with any questions or concerns, these are the most effective ways to get in touch with me within a reasonable amount of time. My regular email is BodyBasedMindfulness@gmail.com, which is not considered to be secure. I also have a secure encrypted email at firstname.lastname@example.org.
Acceptance of this statement and your signature will be required on the mentoring registration form.
1. Please be aware that I, Kent S. Rosengren, Psy.D., am a licensed clinical psychologist in the State of Colorado. By law I am required to have anyone I work with, even in a strict consultative relationship, sign a HIPAA form and provide them with a disclosure statement. All this notwithstanding, I inform everyone that his/her participation in Body Based Mindfulness Consulting is for educational purposes only, and does not in any way constitute a therapist/client relationship between myself and the participant. The participant must agree to and understand this limited consultative relationship and a signature will be required on the consulting registration form.
2. At times, we may discuss topics that might trigger unpleasant memories and/or reactions. You are free at any time to decline to participate in any or all of any possible activities. Please monitor and stay aware of your own mental and emotional wellbeing.
3. Even while I am acting as a consultant, it must be understood that I am a part of a profession required by law to report possible child abuse or neglect if I have “reasonable cause to know or suspect that a child has been subjected to abuse or neglect or who has observed the child being subjected to circumstances or conditions that would reasonably result in abuse or neglect”. If this is the case, I am required to “immediately upon receiving such information report or cause a report to be made of such fact to the county department, the local law enforcement agency, or through the child abuse reporting hotline system as set forth in section 26-5-111, C.R.S”
4. Cancellation Policy – In the event that you need to cancel or reschedule, at least 24 hours notice is required for a full refund, or your payment will be applied to the rescheduled appointment. We understand that emergencies and illnesses occur, therefore one appointment may be cancelled or rescheduled with less than 24 hours notice for a full refund or may applied to the rescheduled appointment. Any further instances of cancellation or rescheduling that occur with less than 24 hours notice will forfeit the full appointment amount.
5. If you desire to contact me with any questions or concerns, these are the most effective ways to get in touch with me within a reasonable amount of time. My regular email is BodyBasedMindfulness@gmail.com, which is not considered to be secure. I also have a secure encrypted email at email@example.com.
Acceptance of this statement and your signature will be required on the consulting registration form.
Kent Rosengren, Psy.D.
1170 Colorado Ave
Grand Junction, CO
Colorado Mandatory Disclosure Statement
1. My name is Dr. Kent Rosengren, Psy.D. I have a doctoral degree in Clinical Psychology from George Fox University and I am licensed as a Clinical Psychologist in the State of Colorado. My license number is 3954. I also completed an APA approved Post-Doctoral Fellowship in Pediatric Psychology from Madigan Army Medical Center. Specialties include individual psychotherapy with children, adolescents, and adults. I have specialized training working with trauma and PTSD with both civilians and veterans. I also do couples and family therapy, psychological testing, and forensic work.
2. The practice of registered, certified or licensed persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The Board of Clinical Psychologists and the Board of Addiction Counselor Examiners can be reached at:1560 Broadway, Ste. 1350, Denver, CO 80202, phone #303-894-7800
3. The Division of Behavioral Health has the general responsibility for regulating practices of licensed substance use disorder treatment programs in the State of Colorado. Questions and complaints may be directed to: Colorado Department of Human Services, Division of Behavioral Health3824 W. Princeton Circle, Denver, CO 80236 (303) 866-7400
4. The regulatory requirements applicable to mental health professionals are as follows:
ü 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 or certified by the State and is not required to satisfy any standardized educational or testing requirements.
ü Certified Addiction Counselor I (CAC I) must be a high school graduate or the equivalent, complete required training hours and 1000 hours of clinically supervised work experience.
ü Certified Addiction Counselor II (CAC II) must be a high school graduate or the equivalent and meet the CAC I requirements, complete additional training hours above the CAC I, and 2000 hours of clinically supervised work experience.
ü Certified Addiction Counselor III (CAC III) must have a Bachelor’s degree in the behavioral health sciences or field, complete additional training above the CAC II, and 2000 hours of clinically supervised work experience.
ü Licensed Addiction Counselor must have a clinical Master’s degree, meet the CAC III requirements, and pass a national examination in addiction treatment.
ü Licensed Social Worker must hold a master’s degree in social work.
ü Psychologist Candidate, Marriage and Family 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.
ü Licensed Clinical Social Worker, Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a master’s degree in their profession and have two years of post-masters supervision.
ü Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision.
5. 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.
6. In a professional relationship, sexual intimacy is never appropriate and should be reported to the Board that registers, certifies or licenses the registrant, certificate holder or licensee.
7. 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. Exceptions to confidentiality may also be found in the Notice of Privacy Rights that can be viewed and downloaded at www.bodybasedmindfulnesscourses.com/files For example, mental health professionals are required to report child abuse to authorities. If a legal exception to confidentiality arises during therapy, if feasible, you will be informed accordingly.
8. I understand that any alcohol and/or drug treatment records are protected under the Federal Confidentiality Regulation, 42 C. F. R., Part 2, governing Confidentiality of Alcohol and Drug Abuse Patient Records. Confidential information cannot be disclosed without my written permission unless otherwise provided for by the regulations.
HIPAA Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
As a Psychologist, I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
• “PHI” refers to information in your health record that could identify you.
• “Treatment, Payment and Health Care Operations”
· Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist.
· Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
· Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
• “Use” applies only to activities within my [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of my [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.
You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse: If, in my professional capacity, a child comes before me which I have reasonable cause to suspect is an abused or maltreated child, or I have reasonable cause to suspect a child is abused or maltreated where the parent, guardian, custodian or other person legally responsible for such child comes before me in my professional or official capacity and states from personal knowledge facts, conditions or circumstances which, if correct, would render the child an abused or maltreated child, I must report such abuse or maltreatment to the statewide central register of child abuse and maltreatment, or the local child protective services agency.
Health Oversight: If there is an inquiry or complaint about my professional conduct to the State Board for Psychology, I must furnish to the Colorado State Board, your confidential mental health records relevant to this inquiry.
Judicial or Administrative Proceedings:If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is privileged under state law, and I must not release this information without your written authorization, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. I must inform you in advance if this is the case
Serious Threat to Health or Safety: I may disclose your confidential information to protect you or others from a serious threat of harm by you.
Worker’s Compensation: If you file a worker’s compensation claim, and I am treating you for the issues involved with that complaint, then I must furnish to the chairman of the Worker’s Compensation Board records which contain information regarding your psychological condition and treatment.
IV. Client's Rights and Psychologist's Duties
Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address.)
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.
Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.
Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process.
Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
· I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
· I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
· If I revise my policies and procedures, I will provide individuals with a revised notice by mail.
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may talk to me directly about it or you may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.
This notice will go into effect on February 20, 2017. I, Kent S Rosengren, Psy.D., reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by mail or email.
End of HIPAA Notice
I have read the preceding information, it has been provided to me verbally, and I understand my rights as a client or as the client’s responsible party.
(Client name, signature, and date will be required on the client form, or course registration form)
Print Client Name
Client Signature or Responsible Party’s Signature Date
_____ (initial) I have read and understand the above and a copy of this disclosure and HIPAA form may be downloaded at http://www.bodybasedmindfulnesscourses.com/files
This is an optional form, by law, I (Dr. Kent S. Rosengren) am required to offer this if you would like limitations on how I contact you. You may download this form at www.bodybasedmindfulnesscourses.com/files You are free to fill in any, all, or none of this information and return it to me at firstname.lastname@example.org:
1. Please telephone me only at the following number(s): ___________________________
When you call please follow these directions: __________________________________
Please do not call me at the following number(s): _______________________________
2. Please direct all postal mail to this address:
Please do NOT send postal mail to this address:
Signature of client or personal representative Date
Printed Name of client or personal representative Relationship to client
Witness Signature Date
_______________________________ _______________ _______________________
For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby grant permission to Body Based Mindfulness Courses and 1000 Beliefs/Rosengren Counseling and Consulting, LLC and its agents or employees to use video and audio (digital media, or any other media) taken of me and my participation in this course/consultation. These images may be used in educational materials such as printed and online mediums. Furthermore, I authorize the use of my image, likeness, and voice, and I acknowledge that I do not expect any remuneration or compensation for all program promotion, materials, and any other purposes, both non-commercial and commercial, in connection with the course/consultation deemed appropriate and/or necessary by Body Based Mindfulness Courses and 1000 Beliefs/Rosengren Counseling and Consulting, LLC, and I hereby waive any right that I may have to inspect and/or approve the finished product to which they may be applied.
I hereby agree to release, defend, and hold harmless Body Based Mindfulness Courses and 1000 Beliefs/Rosengren Counseling and Consulting, LLC and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, including, but not limited to paper, broadcast, videotape, or via electronic/online media, from any claim, damages, or liability arising from or related to the use of the photographs/video, including but not limited to any claims for invasion of privacy, defamation, and libel, misuse, distortion, blurring, alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction, or production of the finished product, its publication, or distribution.
If I am taking part in a course, I do hereby guarantee that any information about the performance of other class participants will be held in confidence, and will not be communicated in any form. I accept and acknowledge that personal recording of any component of this course is strictly forbidden.
I am 18 years of age or older and have read this release before signing below, fully understanding the contents, meaning, and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.
Acceptance of this release and your signature will be required on the course/consultation registration page.