ADULT/YOUTH SERVICES, LLC.

320 N Academy Blvd Suite 205

Colorado Springs, CO 80909

DISCLOSURE STATEMENT

Complaint Procedure

You have the right to a complaint/grievance procedure. Client shall present the complaint in writing to the staff member responsible for the event or situation. If not resolved, client and staff member present the complaint to the staff member's supervisor. If not resolved. client, staff member, and supervisor present complaint to the Executive Director. If you are not comfortable directly addressing the responsible staff member you may present your complaint to the Office Manager or other staff member of your comfort. If your complaint is unable to be resolved within the agency, you may contact the Mental Health Grievance Board.

The practice of licensed or registered individuals is regulated by the Colorado Department of Regulatory Agencies. Any questions, concerns, or complaints regarding the practice of mental health counseling may be directed to:

Department of Regulatory Agencies, Mental Health Section, Telephone: (303) 894-7800

1560 Broadway Suite 1350, Denver, CO 80202

The practice of certified addictions counselors is regulated by the Division of Behavioral Health. Questions, concerns, or complaints regarding Certified Addictions Counselors should be directed to:

Office of Behavioral Health, Telephone: (303) 866-7400

3824 West Princeton Circle, Denver, CO 80236

Disclosure Statement

Adult Youth Services, LLC., is a substance use disorder treatment program licensed by the Office of Behavioral Health, Colorado Department of Human Services. You are entitled to know the name, business address, phone number and credentials of all counselors providing psychotherapy to you in this program. Our staff credentials are as follows:

320 N Academy Blvd Suite 205 Colorado Springs CO. 80909

Counselor names and credentials:

Mary Gupton-Johnson, MSW, LAC, ACD0000934. Ms. Gupton-Johnson earned her Master of Social Work Degree from Newman University with a specialty in Trauma. She is a Registered Psychotherapist in Colorado. She has been employed in the field of counseling for 5 years and utilizes a cognitive behavioral approach to treatment.

Frederick Wells MS NLC.0106071. Mr. Wells, has a Master's in Marriage, Child and Family Therapy degree. He is a Registered Psychotherapist with the state of Colorado. Mr. Wells is a graduated of Phoenix University

Kathleen Robertson, LPC, CAS, ACB0007552. MS. Robertson holds a Master's in Counseling from the University of Northern Colorado. Ms. Robertson has 15 years of progressive experience in the area of mental health and substance abuse.

Timothy (Tim) O'Connor, BA, CAS, ACB0008017. Mr. O'Connor, holds a Bachelor's degree in Social Science Composite from the College of Santa Fe. He has been a Certified Addiction Specialist since 2005. Tim is a retired school teacher and avid hiker.

Sharon Mills, MS, CAS ACB.0008437. A graduate of Denver Seminary of Denver, Colorado Ms. Mills has 19 years of experience in counseling and 3 years in addiction counseling. Supervision Larry Gadson

As to the regulatory requirements applicable to mental health professionals:

A 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- master's supervision. A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision. A Licensed Social Worker must hold a master's degree in social work. A 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 completing the required supervision for licensure. A Certified Addiction Counselor I (CAS) must be a high school graduate and complete required training hours and 1000 hours of supervised experience. A CAS must be additional required training hours and 2000 hours of supervised experience. A CAS must have a bachelor's degree in behavioral health, and complete additional required training hours and 2000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical master's degree and meet the CAS. A registered Psychotherapist is registered with the State Board of Registered Psychotherapists, is not licensed or certified and no degree, training or experience is required. A necessary licensing degree and be in the process of completing the required supervision for licensure. A Certified Addiction Counselor I (CAS) must be a high school graduate and complete required training hours and 1000 hours of supervised experience. A CAS must be additional required training hours and 2000 hours of supervised experience. A CAS must have a bachelor's degree in behavioral health, and complete additional required training hours and 2000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical master's degree and meet the LAC requirements. A registered Psychotherapist is registered with the State Board of Registered Psychotherapists, is not licensed or certified and no degree, training or experience is required.

We provide services in accordance with the following guidelines:

You are entitled to receive information about the methods of therapy, the techniques used, the duration or therapy, if known, and the fee structure.

You may seek a second opinion or terminate therapy at any time.

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 which are listed in the Notice of Privacy Rights that you were provided.

In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant or certificate holder.

Client Signature:

Date:

Clinician Signature:

Date:

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