INFORMED CONSENT AND CONFIDENTIALITY STATEMENT
I
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.
Telemental Health Information -
- We may be using certain technological services and tools, such as Facetime and Zoom.
- Telemental health has both benefits and risks, whilch you and your provider will be monitoring as you proceed with your work.
- You can stop work by telemental health at any time without prejudice.
- You will need to create a private and appropriate space for your sessions.
- You will need to make a plan for managing technology failures, mental health and medical emergencies.
- Your
provider follows security best practices and legal stsandards to protect your
health care information, but you will also need to maintain your own security
and privacy.
Financial Policy –
PAYMENT
IS DUE IN FULL AT THE TIME OF EACH
SESSION. FEES ARE SUBJECT TO
CHANGE EVERY SIX MONTHS.
NO-SHOW AND CANCELLATION POLICY - 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.
By clicking the Submit button, I acknowledge that I have read and understand this information sheet and informed consent.
MCP_______
EVAL_______
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