Please read through the following and provide your electronic signature at the bottom. Each person must provide their own electronic signature for consent.
Dallas Henslee, M.A., L.P.C., N.C.C
NCC-292942 exp. July 31, 2022
Colorado LPC-6075 exp. August 31, 2021
Mark Henslee, Pastoral Care
Client and Counselor/Consulting Disclosure Statement
Thank you for choosing us to walk with you. The following information will help you understand many of the details regarding services provided through Blue Fire Legacy. Our primary commitment is to provide you with quality, time-effective sessions. Below you will find various policies for your information. Please read through these, ask any questions you may have, and sign in the spaces as indicated.
Our methods involve active listening and discussion, problem-solving, and directed activities with solution-focused methods.
We acknowledge our clients have a variety of belief systems, and while we may differ in opinion, it is not our intent to pressure you into assuming a particular belief structure. All services offered through Blue Fire Legacy will incorporate Christian beliefs and values into the sessions. By continuing services with Dallas Henslee and Mark Henslee, you are consenting to Christian counseling, both licensed and pastoral in nature, which will include Judeo-Christian values, the use of Scripture, and prayer in addition to other therapeutic techniques.
Credentials of Therapists
Dallas Henslee holds a Master’s Degree in counseling through Colorado Christian University. She has trained in EMDR and Splankna Therapy, is a Licensed Professional Counselor (LPC) licensed through the state of Colorado, and is additionally credentialed as a Nationally Certified Counselor (NCC).
Continued Education requirements set forth by the state are met and typically exceeded. Additional study is gained through reading, utilizing online resources for self-study, and attending selected seminars most relevant to the scope of practice/ministry.
Consistent with our established moral and ethical position, Colorado law requires that any individual seeking counseling services must be informed that sexual contact between patient and therapist is not a part of any recognized therapy. Sexual intimacy between client/patient and therapist is never appropriate, is illegal, and should be reported in writing to the Department of Regulatory Agencies, Mental Health Section, 1560 Broadway, Suite 1340, Denver, Colorado 80202, or by phone at 303-894-7766. If you have any concerns or complaints about licensed or unlicensed mental health practitioners, you can contact the State Grievance Board.
Additionally, please be aware that although we personally differ in opinion, the State of Colorado takes a position that not ALL memories explored in therapy were actually realized. This will likely only be an issue if for some reason your memories of record were being explored in a court of law.
Mark Henslee offers pastoral care and consulting services. He is an ordained minister and his prior experience as a church planter, pastor, and lay leader help him relate with his clients on an empathetic level.
Services provided through Blue Fire Legacy by Dallas Henslee and Mark Henslee should not be considered medical mental health care. Pastoral or spiritual counsel is provided during our in-person, telehealth, and intensive sessions. When possible, other mental health areas of concern will be discussed with our clients so they may engage the services of another professional counselor to address diagnostic areas.
Blue Fire Legacy operates as an outpatient facility specializing in spiritual and soul care. Therefore, we do not provide emergency care. In the course of treatment should an emergency arise, you may utilize the hospital emergency room, contact the police, call 911, or use a local crisis phone line. Neither of us carries a pager, and our cell phones are only answered during daytime work hours for business related calls.
Fee and Cancellation Policies
As a minister or family member of a minister, the fees for services through Blue Fire Legacy are being sponsored by our generous donors. An appropriate hourly fee for a 50-minute session, referred to as an hour session, is $150 and up depending on the services required. Therefore, we ask that you treat the session as if you were the one responsible for its cost. Our donors are extending an exceptional gift to you.
An appointment is considered missed when the client has not logged into the session, or arrived, within fifteen (15) minutes of the scheduled time.
We will require that clients notify the therapist a minimum of two hours before the scheduled appointment if they are not going to be able to attend the meeting. For missed appointments without proper notice, we will require a contribution to the ministry of $50 be made before rescheduling. The therapist will have the ability to waive this penalty if they deem appropriate.
When a client misses three consecutive meetings, with or without notice, services will be terminated at the discretion of the therapist. The client may request reinstatement of services provided that they demonstrate the needed commitment to the process moving forward.
Should you wish to donate to Blue Fire Legacy in appreciation of services received, you may donate electronically through our website or mail a check to PO Box 1557, Westcliffe, CO 81252. If you have submitted a refundable deposit and would like to donate your refundable deposit, in part or in full, you may indicate on the envelope and/or form provided, otherwise your deposit will be returned to the address previously indicated.
Quality of Care
It is our policy to keep written records of sessions to provide services to the optimum level. These recordings are part of your confidential file and will not be reviewed by anyone without your consent. The only exception to the previous statement regarding confidentiality is that content may be discussed in a peer review consultation or surrendered if required by law.
Confidentiality of services provided is protected by law. Unless you grant us permission to do so in writing, we will neither inform anyone that you are receiving therapy, nor will we disclose the content of any session.
The only circumstance under which such professional confidentiality may be broken is if one or more of the following conditions apply:
1) If you direct us to tell someone else and you have signed a release of information statement allowing a specified person, agency or institution to exchange specific information
2) If you pose a serious physical danger to yourself or another person
3) If you disclose that you or another person has physically or sexually abused or molested a child, an incompetent, or an elderly or disabled person
4) If you disclose that a child, an incompetent, or an elderly or disabled person is suffering because of neglect
5) If there is physical violence (domestic violence)
6) If we are ordered by a court to disclose information
If abuse or neglect is disclosed under the conditions given above, we are mandated by Colorado law to report such information to an appropriate state agency.
Additionally, should we be subpoenaed to testify or produce records, it will be the sole responsibility of the client to cover all costs, including but not limited to legal representation to protect Blue Fire Legacy and its associated parties.
Please understand that while we guard our voicemail and email as carefully as possible, we live in a culture where true confidentiality cannot be guaranteed. You may use either email@example.com or firstname.lastname@example.org to transmit any information you are comfortable addressing through an email platform. Also, remember that Facebook and other social media sites are a very public forum, and you forfeit your privacy by friending, liking pages, or posting while on-line.
By signing this document and any attachments hereto, you agree that we have disclosed sufficient information to enable you to decide to undergo or forgo any of the approaches and other services offered. You understand that your consent to the nature of our sessions is given voluntarily, without coercion, and may be withdrawn at any time in the future. You represent that you are competent and able to understand the nature and consequences of our proposed sessions. You have read and understand the above disclosure about the services offered by Dallas Henslee and Mark Henslee and our differing degrees of training and education and you have discussed with us the nature of the services to be provided, and except in the case of gross negligence or malpractice, agree to release, indemnify, hold harmless and defend Blue Fire Legacy, its stakeholders, board, employees, representatives, and consultants from and against any and all claims of liability, of whatsoever kind or nature, which you, or your representatives, may have for any loss, damage, or injury, including without limitation, physical, emotional, mental, financial, or personal, arising out of or in connection with your sessions.