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Program Information for Clients
Change Co. Impaired Driver Education and Therapy Program
The Level II Alcohol/Drug Driving Countermeasures Program at Rangeview Counseling Center is designed to provide you with accurate information about alcohol/drugs effects and to equip you with new tools for self- knowledge. Our hope is that you will use these tools for your benefit.
The regulations declared by the Colorado Department of Human Services Division of Behavioral Health determine the following:
1. Level II Therapeutic Education shall be restricted to DUI / DWAI or BUI offenders. Level II Therapeutic Education shall total 12 weeks and 24 hours in duration. No more than 1 session shall be conducted per week without clinical justification.
2. Level II Therapy has four treatment tracks. Therapy track assignment depends on how high the risk for repeat offense is assessed by the Alcohol and Drug Evaluation Specialist. The four tracks are as follows:
Track A = Minimum of 42 hours over 21 weeks. Track B = Minimum of 52 hours over 26 weeks. Track C = Minimum of 68 hours over 34 weeks. Track D = Minimum of 86 hours over 43 weeks.
Track F= 180 Months of Therapy
3. Group therapy sessions shall be not less than 90 minutes in length.
4. No part of the Level II Education program shall be counted as part of Therapy.
All group and individual sessions must be attended in order to be reported to the referring probation department and to the Department of Motor Vehicles, Hearing Division, as having completed your program. Further, complete fulfillment of your financial obligation to Rangeview Counseling Center has been defined as a requirement for successful completion.
Clients who miss sessions and have not made arrangements to do so will be reported to the referring agency as having unexcused absences. Three missed sessions within any program is grounds for being discharged and reported to the referring agency as non-compliant and the DMV. If a client has signed up for a make-up or individual session and finds that he/she cannot attend they need to call the office within 24 hours if not they will be charged the cost of the session.
Fees are required to be paid at the beginning of each session. Failure to pay at the time of the session may result in refused entry to the session. Failure to keep fees in a current status can result in being discharged and you will be sent back to the referring agency for their action.
We hope that you enjoy and benefit from your time at Rangeview Counseling Center. If we can be of assistance or help you in any way, please contact one of the staff. If you are having problems please let us know so we can provide assistance.
Rangeview Counseling Center
103 East Simpson St
Rangeview Team are as follows: Susan E. Regan, MSW, LAC- MAC Executive Director
Mallori Kenworthy, LPC, DVOMB Clinical Director
Rangeview Counseling Center
The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Professions and Occupations. The Board, DORA, can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800. Additionally, all driving and substance related services are regulated by: Office of Behavioral Health, can be reached at 3824 W. Princeton Circle, Denver, Colorado 80236, (303) 866-7400.
As to the regulatory requirements applicable to mentalhealth professionals:
✓ 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 by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state.
✓ Certified Addiction Counselor I (CAC I) must be a high school graduate, complete required training hours and 1,000 hours of supervised experience.
✓ Certified Addiction Counselor II (CAC II) must complete additional required training hours and 2,000 hours of supervised experience.
✓ Certified Addiction Counselor III (CAC III) must have a bachelor’s degree in behavioral health, complete additional required training hours and 2,000 hours of supervised experience.
✓ Licensed Addiction Counselor must have a clinical master’s degree and meet the CAC III requirements.
✓ Licensed Social Worker must hold a master’s degree in social work.
✓ Licensed Clinical Social Worker, a 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.
✓ Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Licensed Professional Counselor Candidate must
hold the necessary licensing degree and be in the process of completed the required supervision for licensure.
✓ A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision.
4. 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.
5. 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 certificateholder.
6. 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. For example, mental health professionals are required to report suspected child abuse to authorities. If a legal exception arises during therapy, if feasible, you will be informed accordingly.
7. I have been made aware of Rangeview Counseling Center emergency PlanP&P.
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.
Print Client’s name___________________________________
Notice of Federal Requirements Regarding Confidentiality of Patient Records
The confidentiality of patient records maintained by this program is protected by Federal Law and Regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient unless:
(1) The patient consent in writing,
(2) The disclosure is required by court order, or
(3) The disclosure is made to medical personnel in a medical emergency or to qualified
personnel for research, audit, program evaluation, or certain other information required by state or federal regulations.
Violation of the federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations.
Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime.
Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or Local authorities. (See 42 U.S.C. 190dd-3 and 42 U.S.C. 190-ee-3 for Federal laws and Title 42 CFR V. 1, Part 2 for Federal regulations.)
Rangeview Counseling Center Authorization for Release of Information
I, , authorize RANGEVIEW COUNSELING CENTER to communicate with: (check all that apply)
The Probation Department supervising my case:____________________
The Colorado Division of Motor Vehicles (DMV) _________________
Information will only be released In Accordance With:
“Federal Client Confidentiality Regulations”: 42 Code of Federal Regulations Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records, that protect information that directly or indirectly identifies individuals as current or former substance use disorder treatment clients. These regulations are available from the U.S. Department of Health and Human Services, 200 Independence Ave. SW., Washington, DC 20201 (no later editions are incorporated) or the Colorado Department of Human Services, Alcohol and Drug Abuse Division, 3824 W. Princeton Cir., Denver, CO 80236; or, at any state publication depository library.
“Federal Health Care Information Privacy Regulations”: 45 Code of Federal Regulations Parts 142, 160, 162, 164, the Health Insurance Portability and Accountability Act (HIPAA) that protects the privacy ofall health care information including treatment for substance use disorders, retained by health plans, health care clearinghouses and treatment agencies. These regulations are available from the U.S. Department of Health and Human Services, 200 Independence Ave SW, Washington, DC 20201 (no later editions are incorporated); or, the Colorado Department of Human Services, Alcohol and Drug Abuse Division, 3824 W. Princeton Cir., Denver, CO 80236; or, at any state publication depository library.
Rangeview Counseling Center Attendance and Fee Policies
Welcome to the Change Co.’s Impaired Driver Education Program at Rangeview Counseling Center. The following Attendance and Fees Policies will provide you with guidelines for successfully completing your required hours. If you need assistance, please feel free to ask any one of the counselors.
FAILURE TO ATTEND (FTA): No more than three consecutive FTAs are permitted. After two FTAs, your therapist will call to inquire about the reason for your absence and to learn if we can support your attendance in some way. Under Colorado law, all unexcused absences must be reported. After three FTAs and no communication from you, your probation officer will be notified of your failure to attend and you may be discharged as non-compliant. Failure to attend an Individual appointment, or to give 24 hours notice that you cannot attend, will result in being charged for that appointment at the rate being paid.
EXCUSED ABSENCES (FTAE): You must call prior to the beginning of the class or appointment. Call us at 303-447-2038. You may be excused from attending a class or appointment for the following reasons:
Illness: If you miss more than two weeks, you are required to bring a note from your physician.
Family illness or death: You may be required to providedocumentation.
Emergencies: You may be required to provide documentation.
Vacations: You must make arrangements with your counselor prior to anyvacation.
MAKE-UP CLASSES: Make-up classes for Level II Education AND Therapy are schedule with a individual counselor. Please call the office and we will be happy to fit you in.The cost of make-up is 40.00
FEE PAYMENT: Payment for classes shall be made at the beginning of each class. We accept cash, personal checks, Money Orders made payable to Rangeview Counseling Center or charge cards. If you are unable to make the payment, please make arrangements (prior to the class) for payment with your counselor. “Post- dated” checks are accepted if the date is not past Saturday of that same week. All checks must include the payee’s driver’s license number and current phone number. All balances are managed on a case by case basis and are contingent upon your current standing with the agency. If your account balance is above an approved amount, you will not be permitted into the class until the account balance is at an agreed amount.
If you need to make financial arrangements, see Sliding Scale Policy and speak with the Director(s).
There is a one-time fee of $40.00 for out-takes when client is completed with treatment.
RETURNED CHECKS: A charge of $50.00 will be applied to each returned check. Following notification, a cash payment will be required for the amount of the returned check, plus the $50.00 fee, on or at the start of the next class.
PAYMENT SCHEDULE: All fees must be paid in full by your Outtake. Failure to do so will result in being discharged from the program as incomplete/non-compliant.
I have read, understand, and accept these policies.
What is your occupation?_____________________
How did you get referred for services?_______________________
What are you seeking help for?________________________
How long has this been a problem for you? How has it affected you most?_________________________
Strengths and Resoures
What strengths do you bring to assist with solving this problem? List your strengths and resources:________________________________
History of Mental Illness/Treatment
How many times have you been treated for any psychological or emotional problems: (Do not include substance abuse, employment or familycounseling)______________________
In a Hospital or inpatient setting? _____________With Whom?________________________
In an Outpatient setting?__________________ With Whom?______________________
What for?_________________________ Where?______________ What for?_________________
Experienced trouble understanding, concentrating, or remembering?__________________
Experienced trouble controlling violent behavior, or episodes of rage or violence, including when you have been under the influence of alcohol or drugs?_______________________
Experienced serious thoughts of suicide?________________ Attempted suicide?____________________
Been prescribed medication for any psychological or emotional problems?_______________________
In the past 30 days? _________________Yes ______No___________
How many days in the past 30 have you experienced these psychological or emotional problems?
How much have you been troubled or bothered by these psychological or emotional problems in the past 30 days?
How important to you now is treatment for these psychological or emotional problems?
Health Related Issues/Medical Information
How many times in your life have you been hospitalized for medical problems?__________ Hospitalizations and dates______
Surgeries and dates_________________________
How long ago was your last hospitalization for a physical problem?_____________________
Do you have any chronic medical problems which continue to interfere with your life? If yes, please describe
What treatment, if any, have you received for this problem?___________________________
Do you have any current medical problems? _______________ If yes, please describe
What treatment, if any, have you received for this problem?___________________________
Are you taking any prescribed medication on a regular basis for a physical problem? Please list all medications you are taking, the doses, and what you take them for:________________________
Please list all allergies or adverse drug reactions you have:______________________
Do you receive a pension for a physical disability?___________ Yes No How many days have you experienced medical problems in the past 30 days?________________________
When was your last physical exam (including pap smear if you are female)?______________ What were the results/recommendations?_________________
What is the name and address of your current physician?_________________________
Please indicate if you have had any of the following symptoms:
Had in Past
See or hear things that weren’t there______________
Feeling as though your heart were racing___________
Recent weight loss or gain (circle one)
Frequent/painful urination Stomach/bowel disorders _______________
Epilepsy or seizures Neurological disease Change in memory or concentration_______________________
Male or female reproductive_______________________
Frequent or severe headaches Dizziness or fainting spells________ Eye problems,_______ glaucoma ___
Chronic fatigue Asthma/shortness of breath Chronic cough/lung disorders Palpitation or pounding heart Heart attack/heart trouble ____________High blood pressure___________________
Jaundice/liver disorder Arthritis/gout_____________
problems(i.e. change in menstrual pattern, prostate trouble)____________________
Please list any other diseases or conditions you have had or have now that are not listed above
If you have ever had any of the symptoms listed above, please provide as much of the following information as possible: date of occurrence, duration of illness, symptoms, whether or not treatment was sought, treatment received, results of treatment, and physician’s name. If you did not seek treatment, what was the outcome?
Please indicate your family’s (biological or other) medical history:
Mental Health Diagnosis
Cause of Death and Y ear
Deceased (if applicable)
Name of your Father:
Name of your Mother:
Names of your Siblings:
Have you ever had any of the following health problems? (Check those that apply)
❑ Venereal Warts
❑ Chlamydia ❑ Gonorrhea
❑Tuberculosis ❑ Genital Herpes
How many times have you been pregnant?__________
How many times have you actually given birth?______________
How old were you when your first baby was born?___________________
Are you currently pregnant? Yes No If yes, how far along are you? Have you ever experienced medical complications in childbirth? Yes No If yes, please describ
When were you born?_____________Where were you born_____________
Were you raised by both parents? Yes No
Please describe your childhood:__________________
Please describe how you were disciplined as a child:________________________
What is your current marital status? _____________
Domestic Partnership ❑ Never Married
Remarried Common-law marriage
How long have you been in this marital status?__________________
Are you satisfied with this situation? ___________Yes No Indifferent
How many times have you been married?_____________
Please give your ages and the names of the individuals you have been married to:_________________
Please provide the following information on your biological children:_______ Child’s Name _______Age ___Where living?
From what age to what age?
Please list any other children who are living with you:________________
Name of other parent_______________
Child’s Name Age Names of biological parents________________
What have been your usual living arrangements over the past three years?
❑ With romantic partner and children ❑ With parents
❑ With romantic partner alone
❑ With family
❑ Controlled environment (jail, etc.)
❑ With children alone
❑ With friends
❑ No stable arrangement
How long have you lived in these arrangements?___________________
Are you satisfied with these arrangements? Yes No Do you live with anyone who: has a current alcohol problem?____________
uses non-prescribed drugs? _______With whom do you spend most of your free time? __________
Are you satisfied with spending your free time this way? _______ About how many close friends do you have?_________
Would you say you have had a close reciprocal relationship with any of the following people?
Your mother (parent 1) Your father (parent 2) Siblings
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
❑ Uncertain ❑ Uncertain ❑ Uncertain
Romantic partner/Spouse Children
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
❑ Uncertain ❑ Uncertain ❑ Uncertain
In your lifetime /Yes No
Have you had significant periods in which you have experienced serious problems getting along with:
In the past 30 days In your lifetime
In the past 30 days
Your mother (parent 1)
Your father (parent 2)
Romantic partner/Spouse Other family members (specify)
Have you ever been abused If so, please elaborate:
physically ______emotionally?_______ sexually?_________
How many years of education have you completed?________________
Do you have a profession, trade or skill? ________________If so, please specify
Do you have a valid driver’s license? ________________
How many years of job training or technical education have you received?
Do you have an automobile available? _____________How long was your longest full-time job?______________
What is your usual, or last occupation?___________________
large business owner
❑Clerical/sales/direct service (Technician, Bookkeeper, etc.)
(Hospital Aide, Waiter, etc.)
❑ Homemaker ❑ Other
small business owner
(Construction, Electrician, etc.)
Does someone contribute to your support in any way? Yes /No If so, does this constitute the majority of your support? Yes No
What has been your usual employment
pattern the past three years? Full time (35 + hours)Part Time
❑ Military Service ❑ Unemployed
How many days were you paid for working in the past 30 days?_________________
How much money did you receive from the following sources in the past 30 days?_____________
Unemployment compensation Welfare, disability benefits Pensions, Social Security Partner, family or friends Illegal sources
How many people depend on you for the majority of their food, shelter, etc.? How many days have you experienced employment problems in the past 30 days?____________________
Unskilled or unemployed (Janitor, attendant, etc.)
Student, disabled or no occupation
)Part time (regular hours) Part time (irregular hours) Retired/disability
In controlled environment
How troubled or bothered have you been
by employment problems in the past 30 days?_____________________
How important is counseling for employment problems?________________
Please indicate your history of drug and alcohol use.
How old were you when you first used it?
When was your last use?
Over the last year, how
often have you used the substance? (i.e. every day, once a week, etc.)
Over the last year,
what is the normal amount you use in a 24 hr. period of time?
What is the most you have ever used in a 24 hr. period of time?
How have you used it?
Cigarettes, Cigars, Chew
❑ Smoke ❑ Oral
❑ Oral ❑ Oral
❑ Smoke ❑ Oral
Beer, Wine Hard liquor
Marijuana, Hash, Oils
Rock, Crack, Powder
❑ Inject ❑ Smoke ❑ Snort
Crystal Meth, Crank, Ice
❑ Inject ❑ Smoke ❑ Snort
Speed, Diet pills, White crosses
PAIN PILLS Demerol, Darvon, Percocet, Percodan, Tylenol with Codeine
Downers, Reds, Yellows, Quaaludes, 71
Valium, Xanax, Ativan
Gas, Glue, Solvent, Paint, Poppers, Rus PCP Angel Dust OTHER (please list)
OTHER (please list)
❑ Inject ❑ Oral
❑ Oral ❑ Inject
❑ Oral ❑ Inhale
LSD, Acid, Mushrooms, Peyote
❑ Eye Drops ❑ Oral
Morphine, Heroin, Opium, Methadone
❑ Inject ❑ Smoke ❑ Oral
Which substance do you see as the major problem for you?___________________________
How long was your last period of voluntary abstinence from this major substance?_______________________
How many months ago did this abstinence end?______________________________
Have you ever experienced withdrawal symptoms several hours to several days after stopping or reducing your drug or alcohol use? Yes /No
If yes, please indicate the symptoms you have experienced:
❑ Nausea, vomiting or diarrhea
❑ Increased heart rate or blood pressure ❑ Little or no energy
❑ Significant weight loss or weight gain
Sleep problems (too much or too little) Anxiety, depression or irritability Sweating
Significant increase or decrease in appetite Seeing or feeling things that aren’t there
Achy joints or muscles Poor concentration Runny nose or eyes
Have you ever “blacked out” or lost periods of time when you were using drugs and/or alcohol? Yes/ No
Have you noticed that throughout your use history you have needed to use more and more drugs and/or alcohol to get drunk or high? Yes/ No
Have you ever received complaints from your family, friends, employer or others around you concerning your drug and/or alcohol use, or concerning your behavior while using? Yes/ No
How many times in your life have you been treated for Alcohol abuse?___________________
How many of these were Detox only?______ Alcohol abuse?________
How much money would you say you spent during the last 30 days on Alcohol?_______________
How many days have you been treated as an outpatient for alcohol or drugs in the past 30 days? How many days have you been treated as an inpatient for alcohol or drugs in the past 30 days?________________
How troubled or bothered have you been
in the past 30 days byAlcohol Problems? _______________
Were you referred by the Colorado criminal justice system?_______________
Are you currently on Colorado parole or probation Yes/No
Have you been convicted of a crime in another state (including DUI)?____________________
If yes, are you currently on probation, parole, or deferred sentence for a crime in another state? Yes /No If yes, are you under, or will you be under, the supervision of a probation officer or parole officer in Colorado, pursuant to the Interstate Compact? Yes /No If so, who is that person?
Have you been approved to receive treatment in Colorado by the Interstate Compact Office? Yes/ No
How many times in your life have you been arrested and charged with the following:
Shoplifting/vandalism ____ Parole/probation violation ____ Drug charges
Forgery Weapons offense Burglary/larceny/ breaking and entering ,Assault Arson Rape
Homicide/manslaughter ____ Prostitution ____ Contempt of court
Other (please specify) _____
How many of these charges resulted in convictions?______________
How many times in your life have you been charged with the following?__________________
Disorderly conduct, vagrancy, or public intoxication_________________
What has been your highest measured Blood Alcohol Level?__________ How many months were you incarcerated in your life?
How long was your last incarceration? _________What was it for?_____________
( check here if not applicable)
How many days in the past 30 were you detained or incarcerated?___________________
How many days in the past 30 have you engaged in illegal activities for profit?_________________
Driving while intoxicated Major driving violations________________
How serious do you feel your present legal problems are?_________________
How important to you now is counseling or referral for these legal problems?_______________
What I would like to get out of this program
Take a few moments to think of what you might like to get out of this program. Write them in the space below. It could be as simple as getting through the program quickly as possible or as complex as learning to always drink responsibly.