Patient Health Questionnaire-9 (Phq-9) Template/form Gad-7 Page 4
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8Neal Brugman, Psy.D.
(720) 295-7605
licensed professional counselor, licensed marriage and family therapist, licensed addiction
counselor, or an registered psychotherapist. If the information is confidential, the therapist
may not disclose the information without the client’s consent. There are exceptions to the
general rule of legal confidentiality, which are listed in the Colorado Statutes (C.R.S. 12-43-
218). Examples of such exceptions include but are not limited to a client who is an imminent
danger to self or others and report or evidence of child abuse or neglect. You should be
aware that provisions concerning disclosure of confidential communications shall not apply
to any delinquency or criminal proceedings, except as provided in section 13-90-107 C.R.S.
I will identify any exceptions to you if any such exceptions arise while the therapeutic
relationship exists or after we have terminated the therapeutic relationship.
The standards of the profession dictate that clinical documentation of therapy must be
maintained. If you have any questions or would like additional information, please feel free
to ask.
Consent for Treatment (check one)
I ________________________ voluntarily consent to mental health and/or consultative services
with Neal Brugman, Psy.D.
I ________________________ voluntarily consent to mental health and/or consultative services
for my minor child, ________________________ with Neal Brugman, Psy.D.
Financial Agreement
Standard Service Fees:
Please review the rates for the following services. The rates listed below are based on a 45-
50 minute clinical hour. Therapeutic sessions lasting over 50-minutes in length may be
subject to additional service fees.
Psychotherapy:
o Individual Therapy: $125 (50 minute session)
o Group therapy: $50 (90 minute session)
o Phone consults (over 15 minutes in length): $125/ hour
o After-Hours Consultations: $135/hour
Phone, Email or Internet Chat (i.e. Skype) Policies:
When meeting face-to-face is not an option, it is possible we can communicate in other
ways. The first 15 minutes of time spent between regular sessions is included with your
psychotherapy fee. If you feel that you would like to communicate for more than 15 minutes
on the phone, then a prorated fee will be charged to your account based on the time spent
on the phone. Skype or phone sessions are scheduled in the same way that a regular in-
person session would be and the fee is the same.
Short emails regarding scheduling will not incur a fee, but if you would like your therapist
to read a longer email and respond as they would in a therapy session then charges will
based on the time spent to do so. Please feel free to talk to your therapist more about these
policies if you have any questions.
Psychological Assessments:
Unless otherwise arranged, psychological assessments are billed at $125 per hour. Prior to
beginning an assessment an estimate of the total number of hours needed to complete the
assessment will be provided. Psychological assessments are billed on an ongoing basis.
The Collaborative Center, LLC
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