Colorado Mandatory Disclosure The Colorado State Department of Regulatory Agencies regulates the practice of both licensed and unlicensed persons in the field of psychotherapy. Any questions, concerns or complaints regarding the practice on mental health/drug and alcohol treatment may be directed to the State Boards listed below. You are entitled to receive information about the methods of therapy, the techniques used, the duration of therapy, and the fee structure. You may seek a second opinion from another therapist or may terminate therapy at any time. You should know that in a professional relationship, sexual intimacy is never appropriate and should be reported to the grievance board. You should understand the information provided by you during therapy is legally confidential in the case of psychologists. There are exceptions, which can be discussed and will be identified should any such situations arise during the course of therapy. Dr. Antoinette Gomez LCSW, MSW, CAC III is certified through the State of Colorado to provide counseling services and to facilitate Alcohol and Other Drug abuse/dependence treatment services: Mental Health Occupation Grievance 1560-Broadway, Suite 1340 Denver, CO 80236 303.894.7766 DORA 1560 Broadway, #135 Denver, CO 80202 303.894.7766 I have been informed of my therapist’s degrees, credentials, and Licenses. I have also read preceding information and understand my rights as a participant. Participant's signature Date * All staff that holds a certified addiction counseling license has a mandatory disclosure that everyone who attends the Sisters of Color United for Education must sign when attending orientation.