RTS Weekend Informed Consent Agreement

Please read the following Restoring the Soul Weekend Intensive informed consent and mandatory disclosure agreement carefully before signing below. If you have any questions or concerns, contact Brian Boecker here.

Informed Consent & Mandatory Disclosure

Restoring The Soul & RTS Weekend Intensive
7175 W Jefferson Ave Suite 4400, Lakewood, CO 80235

Thank you for choosing Restoring the Soul and welcome to the Men’s Weekend Intensive. It is a privilege to serve you and help you accomplish your goals. It is our commitment throughout the weekend to you to provide the highest quality counseling and spiritual care. Please take a moment and review the following information for the Restoring the Soul Men’s Weekend Intensive.  If you have any questions, please don’t hesitate to bring them to our attention.

The Program Director and Clinical Director during the weekend is Michael John Cusick, M.A., L.P.C. whose education and credentials are: Michael Cusick, MA: Licensed Professional Counselor (LPC) in Colorado (License #957); Bachelor of Arts, Social Studies, Cleveland State University; Master of Arts, Biblical Counseling, Colorado Christian University; Master of Arts, Counseling Psychology, The University of Denver, Certified Clinical Trauma Specialist.

The Unique Nature of the Restoring the Soul Men’s Weekend Intensive

Soul care intensives are named as such because they are emotionally and physically demanding. It’s important to know that intensive soul care is distinct from traditional counseling. The time you spend with Restoring the Soul is highly concentrated within a one or two-week timeframe. Participants should be aware that meeting daily for three hours may result in emotional and physical depletion. For this reason, we ask that you wholly direct your time and attention to the issues at hand and refrain as much as possible from work or outside responsibilities. While Restoring the Soul offers a complimentary follow-up phone session (please see additional document), we cannot guarantee follow-up soul care or psychotherapy after your intensive has been completed. We strive to make recommendations for your further healing and growth.

  1. The time you spend at the RTS Men’s Weekend Intensive is highly concentrated within a sixty-six-hour time frame between Thursday evening and Sunday at noon. Participants should be aware that participation may result in emotional and physical depletion. For this reason, we ask that you notify staff with concerns or need for support.
  2. Unlike traditional counseling, the counseling and care you receive will include experiential healing work in large and small groups, solitude, and contemplation, both in and out of doors as weather permits.
  3. At the time of onsite registration, all participants will be asked to voluntarily surrender personal possessions, including wallets, watches, electronic devices such as phones, tablets, computers, or any other non-essential (such as medical) items. Surrendering items is voluntary and all items will be stored in a locked room until the appointed time during the weekend.

Disclosure Regarding Divorce and Custody Litigation

If you are involved in divorce or custody litigation, it is not the role of Michael John Cusick, M.A., L.P.C or other Weekend Intensive staff to make recommendations regarding custody or parenting issues to the court. By signing this Disclosure Statement, you agree not to subpoena Michael John Cusick, M.AL.P.C. or other staff or counselors under his direction, to court for testimony or for disclosure of treatment information and you will not request the therapist write any reports to the court or to your attorney regarding recommendations concerning custody or parental responsibilities. The court can appoint a professional to make an evaluation and recommendations.

Mandatory Disclosure in The State of Colorado

The Colorado Department of Regulatory Agencies requires that all mental health counselors and psychotherapists provide their clients the following information at the first session.

  1. You are entitled to receive information about the methods of counseling and soul care, the techniques used, the duration of care, as well as the fee structure.
  2. You may seek a second opinion from another therapist or caregiver or terminate the weekend intensive at any time. Should you decide to terminate the intensive during or after the initial session, all deposits and fees still apply and will be billed according to the financial agreement.
  3. In a professional counseling relationship or in any caregiving relationship, sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the Colorado State Grievance Board (see below).
  4. The Colorado Department of Regulatory Agencies (DORA) has the general responsibility of regulating the practice of licensed psychologists, licensed social workers, licensed professional counselors, licensed marriage and family therapists, licensed school psychologists practicing outside the school setting and unlicensed individuals who practice psychotherapy.
  5. The agency within the Department that has responsibility specifically for licensed and unlicensed psychotherapists is:

Department of Regulatory Agencies, Mental Health Section
1560 Broadway, Suite 1350
Denver, Colorado 80202
(303) 894-7766

Your Rights and Our Requirements Regarding Confidentiality

As a licensed professional counselor, there is a legal privilege in the state of Colorado protecting the confidentiality of the information that you share with your caregiver. This means that if for whatever reason your caregiver was subpoenaed into court to testify regarding a matter for which you were before the court, your caregiver could not be compelled to testify against your wishes. Further, as professionals, we can assure you that we strive to maintain the strictest ethical standards of confidentiality.

There are important legal exceptions to confidentiality. It is our policy to work only with those clients who irrevocably agree that the right to confidentiality is waived in the following situations:

(a) Imminent danger to self or others (suicidality and homicidality)

(b) Legal requirements to report child or elder abuse

(c) Grave disability from a mental illness

(d) When you provide written authorization to release information

Any questions, concerns, or complaints regarding the practice of psychotherapy or other mental health professions may be directed to:

Colorado State Grievance Board
1560 Broadway, Suite 134
Denver, Colorado  80202
303.894.7766

Informed Consent for Treatment

As a participant of the Restoring the Soul Men’s Weekend Intensive, I have read, understood or asked for clarification about the information and policies presented in this form. I consent to receiving soul care services under these conditions. I freely choose to participate in the Restoring the Soul’s Men’s Weekend Intensive and consent to receiving soul care services with full knowledge of the above information.

Restoring the Soul Staff Signature

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Brian Boecker

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