5525 Erindale Drive, Suite 122

Colorado Springs, CO 80918

Office: 719-266-0724

Carol Kryder, LPC

Cell: 719-660-8844
FAX: 719-594-0116
ckryderlpc@msn.com
www.carolkryder.com
Diplomate, American Psychotherapy Association

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

INFORMED CONSENT: Sometimes addressing issues and emotions can cause

unforeseen problems; in fact, sometimes things get worse before they get better. In
very rare cases there can be a risk with psychotherapy that is not predictable. Please
initial and date where indicated that you understand this risk and have had all your
questions answered satisfactorily.

____________________________________________________ ________________
Name Date
5525 Erindale Drive, Suite 122
Colorado Springs, CO 80918
Office: 719-266-0724

Carol Kryder, LPC

Cell: 719-660-8844
FAX: 719-594-0116
ckryderlpc@msn.com
www.carolkryder.com
Diplomate, American Psychotherapy Association

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)________________________________

Underline any of the following which apply to the client:

Headaches Inferiority feelings Marked mood changes
Fainting Homocidal ideas Loneliness
Dizziness Suicidal ideas Legal difficulties
Memory problems Past suicidal attempts Past court involvement
Irritability Guilt Employment problems
Restlessness Difficulty making decisions Inadequate income
Anxiety Unwanted thoughts Eating disorder
Panic attacks Brooding School problems
Thought racing Preoccupations Problem with anger
Depression Compulsions Victim of child abuse
Fatigue Heart palpitations Drinking too much
Frequent worries Problem concentrating Past drug/alcohol abuse
Poor appetite Difficulty relaxing Drug problem
Overeating Stomach trouble Family problems
Weight change Bowel problems Sexual problems
Vomiting Unusual experiences Difficulty making friends
Insomnia Hallucinations Difficulty keeping friends
Excessive sleep Difficulty trusting people Loss of important relationship
Nightmares Paranoid thoughts/feelings Poor church/religious support
HIV exposure Sexual abuse Domestic violence
Others________________________________________________________________
Chief complaints that brought you to this office:_______________________________
_____________________________________________________________________
How many years of school have you completed?________ Degree held ___________
Family physician ______________________ Date of last physical exam ___________
Daily amount used: Alcohol___________ Marijuana___________ Coffee __________
Colas ____________Tea _______________ Cigarettes _______
Types and frequency of exercise: __________________________________________
Leisure time activities: ___________________________________________________
 5525 Erindale Drive, Suite 122
Colorado Springs, CO 80918
Office: 719-266-0724

Carol Kryder, LPC

Cell: 719-660-8844
FAX: 719-594-0116
ckryderlpc@msn.com
www.carolkryder.com
Diplomate, American Psychotherapy Association

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

□ □ □ Alcoholism_________________ □ □ □ Heart/high blood pressure_______

□ □ □ Depression_________________ □ □ □ Thyroid/diabetes______________
□ □ □ Suicide____________________ □ □ □ Cancer______________________
□ □ □ Mental Illness_______________ □ □ □ Epilepsy/retardation____________
□ □ □ Other familial diseases____________________________________________
Important non-blood relatives with mental illness, suicide/homicide (i.e. step-parents,
spouse)_______________________________________________________________

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

Carol Kryder, LPC

Cell: 719-660-8844
FAX: 719-594-0116
ckryderlpc@msn.com
www.carolkryder.com
Diplomate, American Psychotherapy Association

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:

_____ $125 Intake/Evaluation (60 minutes)

_____ $100 Individual Therapy Session (45 minutes)
_____ $125 Family Therapy Session (50 minutes)
_____ $ 80 Missed Appointment fee (no show-no call)
_____ $ 30 Returned check fee

I agree to pay a sliding scale fee at each session of ____________________mutually agreed

upon by Carol Kryder, MA, LPC and myself.

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

_________________________________ ________ _______________________________

Name Date Signature

_________________________________ ________
Witness Date
5525 Erindale Drive, Suite 122
Colorado Springs, CO 80918
Office: 719-266-0724

Carol Kryder, LPC

Cell: 719-660-8844
FAX: 719-594-0116
ckryderlpc@msn.com
www.carolkryder.com
Diplomate, American Psychotherapy Association

CLIENT RIGHTS AND EXPECTATIONS

As a client of Carol Kryder, MA,LPC, treatment is offered to you without

discrimination as to age, gender, race, creed, sexual preference or country of origin in
accordance with the Civil Rights Act of 1964.

• 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

_____________________________ _________ _____________________________

Name Date Signature
 5525 Erindale Drive, Suite 122
Colorado Springs, CO 80918
Office: 719-266-0724

Carol Kryder, LPC

Cell: 719-660-8844
FAX: 719-594-0116
ckryderlpc@msn.com
www.carolkryder.com
Diplomate, American Psychotherapy Association

NOTICE OF USE OF PRIVATE HEALTH INFORMATION (HIPPA)

Effective Date: April 14, 2003
This notice describes how medical information about you may be used and disclosed and how you
can get access 10 this information, Please review it carefully.

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.

I ________________________________ acknowledge that I have received a copy of

NOTICE OF USE OF PRIVATE HEALTH INFORMATION.
If I have any questions regarding these rights, I will contact Carol Kryder at the
address or telephone number listed above.

___________________________________________________ _______________
Signature of Client, Parent or Guardian Date
5525 Erindale Drive, Suite 122
Colorado Springs, CO 80918
Office: 719-266-0724

Carol Kryder, LPC

Cell: 719-660-8844
FAX: 719-594-0116
ckryderlpc@msn.com
www.carolkryder.com
Diplomate, American Psychotherapy Association

PATIENT RECORD OF DISCLOSURES

In general, the HIPPA privacy rule gives individuals the right to request a restriction on
uses and disclosures of their protected health information (PHI). The Individual is also
provided the right to request confidential communications of that a communication of
PHI be made by alternative means, such as sending correspondence to the individual’s
office instead of the individual’s home.

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.

I WISH TO BE CONTACTED IN THE FOLLOWING MANNER:

Home Telephone ______________________________________________

Leave call back information only __________________________________
Work Telephone _______________________________________________
Leave call back information only __________________________________

Written Communication (horne)______________ (office) _______________

May we contact you at your email address? Yes _______ No _________