Now Offering Online Virtual Counseling
INFORMED CONSENT AND CONFIDENTIALITY STATEMENT
understand and agree to the following:
- that treatment offered is
voluntary in nature, unless I am under the age of 18.
- that, within certain limits,
information that may be revealed during therapy will be kept strictly
confidential, requiring a written authorization from all parties in treatment
if any information is to be released to any outside parties, with the exception
of my insurance company.
- that if I reveal information
indicating that I may be a threat either to myself or others, my therapist may
be permitted and/or mandated by law to reveal this information to other persons
or agencies for the safety of myself or others. This would include instances of
suspected child abuse when treating a child under 18 years of age.
Health Information -
may be using certain technological services and tools, such as Facetime and
health has both benefits and risks, whilch you and your provider will be
monitoring as you proceed with your work.
can stop work by telemental health at any time without prejudice.
will need to create a private and appropriate space for your sessions.
will need to make a plan for managing technology failures, mental health and medical
provider follows security best practices and legal stsandards to protect your
health care information, but you will also need to maintain your own security
IS DUE IN FULL AT THE TIME OF EACH
SESSION. FEES ARE SUBJECT TO
CHANGE EVERY SIX MONTHS.
- Your visit has been reserved for you. 24
hours notice is required for cancellation or you will be charged a late cancellation
fee of $75.00.
clicking the Submit button,
I acknowledge that I have read and understand this information sheet and