Other Points. If you ever become involved in a divorce or custody dispute, I want you to understand and agree that I will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on two reasons: (1) My statements will be seen as biased in your favor because we have a therapy relationship; and (2) the testimony might affect our therapy relationship, and I must put this relationship first. 04.13.17 Patient Name: Medical Record Number: Xxxx-Xxxxx Xxxxxxx, M.D. Apex Child, Adolescent & Adult Psychiatry, p.A. Apex, North Carolina Our Agreement I, the client (or his or her parent or guardian), understand I have the right not to sign this form. My signature below indicates that I have received this Agreement; it does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the psychiatrist, before I start (or the client starts) formally working together and even after the work has begun. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in this brochure, I can talk with you about them, and you will do your best to answer them. I understand that after treatment begins I have the right to withdraw my consent to treatment at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending treatment with you. I understand that no specific promises have been made to me by this physician, about the results of treatment, the effectiveness of the procedures used by this doctor, or the number of sessions necessary for treatment to be effective. I have read, will read, or have had read to me, the issues and points in this Agreement. I have discussed or will discuss those points I did not understand, and will have/have had my questions, if any, fully answered. I agree to act according to the points covered in this Agreement. I hereby agree to work with this psychiatrist, and to cooperate fully and to the best of my ability, as shown by my signature here. Signature of client (or person acting for client) Date Printed name Relationship to client Signature of physician Date I truly appreciate the chance you have given me to be of professional service to you, and look forward to a successful relationship with you. If you are satisfied with my services as we proceed, I (like any professional) would appreciate your referring other people to me who might also be able to make use of my services.
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Samples: static1.squarespace.com
Other Points. If you ever become involved in a divorce or custody dispute, I want you to understand and agree that I will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on two reasons: (1) My statements will be seen as biased in your favor because we have a therapy relationship; and (2) the testimony might affect our therapy relationship, and I must put this relationship first. 04.13.17 Patient Name: Medical Record Number: XxxxXXXX-Xxxxx XxxxxxxXXXXX XXXXXXX, M.D. Apex ChildAPEX CHILD, Adolescent ADOLESCENT & Adult PsychiatryADULT PSYCHIATRY, p.A. ApexP.A. APEX, North Carolina NORTH CAROLINA Our Agreement I, the client (or his or her parent or guardian), understand I have the right not to sign this form. My signature below indicates that I have received this Agreement; it does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the psychiatrist, before I start (or the client starts) formally working together and even after the work has begun. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in this brochure, I can talk with you about them, and you will do your best to answer them. I understand that after treatment begins I have the right to withdraw my consent to treatment at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending treatment with you. I understand that no specific promises have been made to me by this physician, about the results of treatment, the effectiveness of the procedures used by this doctor, or the number of sessions necessary for treatment to be effective. I have read, will read, or have had read to me, the issues and points in this Agreement. I have discussed or will discuss those points I did not understand, and will have/have had my questions, if any, fully answered. I agree to act according to the points covered in this Agreement. I hereby agree to work with this psychiatrist, and to cooperate fully and to the best of my ability, as shown by my signature here. Signature of client (or person acting for client) Date Printed name Relationship to client Signature of physician Date I truly appreciate the chance you have given me to be of professional service to you, and look forward to a successful relationship with you. If you are satisfied with my services as we proceed, I (like any professional) would appreciate your referring other people to me who might also be able to make use of my services.
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Samples: static1.squarespace.com
Other Points. If you ever become involved are unhappy with what is happening in a divorce or custody disputetherapy, I want hope you will talk with me so that I can respond to your concerns. These comments will be taken seriously and handled with care and respect. You may also request that I refer you to understand another therapist, and agree you are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not provide evaluations have social or expert testimony in courtsexual relationships with clients or with former clients. You should hire a different mental health professional for any evaluations or testimony you requireOUR AGREEMENT Please initial each statement and sign below. This position is based on two reasons: (1) My statements will be seen as biased in your favor because we have a therapy relationship; and (2) the testimony might affect our therapy relationship, and I must put this relationship first. 04.13.17 Patient Name: Medical Record Number: Xxxx-Xxxxx Xxxxxxx, M.D. Apex Child, Adolescent & Adult Psychiatry, p.A. Apex, North Carolina Our Agreement I, the client (or his or her parent or guardian), understand I have the right not to sign this form. My signature below indicates that I have received read and discussed this Agreement; it agreement. It does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the psychiatristtherapist, before I start (or the client starts) formally working together and even after the work has begunformal therapy. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in this brochure, I can talk with you about them, and you will do your best to answer them. I understand that after treatment begins therapy begins, I have the right to withdraw my consent to treatment therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending treatment therapy with you. I understand that no specific promises have been made to me by this physician, therapist about the results of treatment, the effectiveness of the procedures used by this doctortherapist, or the number of sessions necessary for treatment therapy to be effective. I have read, will read, or have had read to me, the issues and points in this Agreement. I have document, discussed or will discuss those points I did not understand, and will have/have had my questions, if any, questions fully answered. I agree to act according to the points covered in this Agreementhere. I hereby agree to work enter into therapy with this psychiatristtherapist, and to cooperate fully and to the best of my ability, as shown by my signature here. MY SIGNATURE BELOW INDICATES THAT I HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. IT ALSO SERVES AS AN ACKNOWLEDGEMENT THAT I HAVE RECEIVED THE HIPAA NOTICE DESCRIBED ABOVE. Signature of client (or person acting for client) Date Printed name Relationship to client Signature of physician Date I truly appreciate the chance you have given me to be of professional service to you, and look forward to a successful relationship with you. If you are satisfied with my services as we proceed, I (like any professional) would appreciate your referring other people to me who might also be able to make use of my services.Date
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Samples: Psychotherapy Service Agreement
Other Points. If you ever become involved in a divorce or custody dispute, I want you to understand and agree that I will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on two reasons: (1) My statements will be seen as biased in your favor because we have a therapy relationship; and (2) the testimony might affect our therapy relationship, relationship and I must put this relationship first. 04.13.17 Patient Name: Medical Record Number: Xxxx-Xxxxx XxxxxxxIf, M.D. Apex Childas part of our therapy, Adolescent & Adult Psychiatryyou create and provide to me records, p.A. Apexnotes, North Carolina Our Agreement artworks, or any other documents or materials, I will return the originals to you at your written request but will retain copies. If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients. OUR AGREEMENT I, the client (or his or her parent or guardian), understand I have the right not to sign this form. My signature below indicates that I have received read and discussed this Agreementagreement; it does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the psychiatristtherapist, before I start (or the client starts) formally working together and even after the work has begunformal therapy. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in this brochure, I can talk with you about them, and you will do your best to answer them. I understand that after treatment therapy begins I have the right to withdraw my consent to treatment therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending treatment therapy with you. I understand that no specific promises have been made to me by this physician, therapist about the results of treatment, the effectiveness of the procedures used by this doctortherapist, or the number of sessions necessary for treatment therapy to be effective. I have read, will read, or have had read to me, the issues and points in this Agreementdocument. I have discussed or will discuss those points I did not understand, and will have/have had my questions, if any, fully answered. I agree to act according to the points covered in this Agreementbrochure. I hereby agree to work enter into therapy with this psychiatristtherapist (or to have the client enter therapy), and to cooperate fully and to the best of my ability, as shown by my signature here. Signature of client (or person acting for client) Date Printed name Relationship to client Signature of physician Date I truly appreciate the chance Your signature below indicates that you have given me read the information in this document and agree to be of abide by its terms during our professional service to you, and look forward to a successful relationship with yourelationship. If you are satisfied with my services as we proceed, I YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA DESCRIBED ABOVE. SIGNATURE OF CLIENT DATE IF CLIENT IS A MINOR: CHILD’S NAME SIGNATURE OF PARENT #1 DATE PRINTED NAME SIGNATURE OF PARENT #2 DATE (like any professional) would appreciate your referring other people to me who might also be able to make use of my services.REQUIRED IF PARENTS ARE SEPARATED OR DIVORCED AND HAVE JOINT LEGAL CUSTODY)
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Other Points. If you ever become involved are unhappy with what is happening in a divorce or custody disputetherapy, I want hope you will talk with me so that I can respond to your concerns. These comments will be taken seriously and handled with care and respect. You may also request that I refer you to understand another therapist, and agree you are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not provide evaluations have social or expert testimony in courtsexual relationships with clients or with former clients. You should hire a different mental health professional for any evaluations or testimony you requireOUR AGREEMENT Please initial each statement and sign below. This position is based on two reasons: (1) My statements will be seen as biased in your favor because we have a therapy relationship; and (2) the testimony might affect our therapy relationship, and I must put this relationship first. 04.13.17 Patient Name: Medical Record Number: Xxxx-Xxxxx Xxxxxxx, M.D. Apex Child, Adolescent & Adult Psychiatry, p.A. Apex, North Carolina Our Agreement I, the client (or his or her parent or guardian), understand I have the right not to sign this form. My signature below indicates that I have received read and discussed this Agreement; it agreement. It does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the psychiatristtherapist, before I start (or the client starts) formally working together and even after the work has begunformal therapy. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in this brochure, I can talk with you about them, and you will do your best to answer them. I understand that after treatment begins therapy begins, I have the right to withdraw my consent to treatment therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending treatment therapy with you. I understand that no specific promises have been made to me by this physician, therapist about the results of treatment, the effectiveness of the procedures used by this doctortherapist, or the number of sessions necessary for treatment therapy to be effective. I have read, will read, or have had read to me, the issues and points in this Agreement. I have document, discussed or will discuss those points I did not understand, and will have/have had my questions, if any, questions fully answered. I agree to act according to the points covered in this Agreementhere. I hereby agree to work enter into therapy with this psychiatristtherapist, and to cooperate fully and to the best of my ability, as shown by my signature here. MY SIGNATURE BELOW INDICATES THAT I HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. Signature of client (or person acting for client) Date Printed name Relationship to client Signature of physician Date I truly appreciate the chance you have given me to be of professional service to you, and look forward to a successful relationship with you. If you are satisfied with my services as we proceed, I (like any professional) would appreciate your referring other people to me who might also be able to make use of my services.Date
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Samples: virginialindahl.com
