Common Contracts
1 similar Therapy Services Agreement contracts
Therapy Services Agreement AdultTherapy Services Agreement • February 4th, 2022
Client Information Client’s Name: Date of Birth (yyyy-mon-dd): Full Address: Phone Number: Is it okay to leave a message? E-mail: Is it okay to communicate through e-mail? (please note, confidentiality cannot be guaranteed via e- mail) Confidentiality All communication regarding treatment and all records relating to the provision of therapy services are confidential and will not be disclosed without written consent. The law does however; place limits on confidentiality related to specific disclosures. These include:1. Risk of imminent danger to self or other2. Abuse of child or a vulnerable adult3. Court ordersIf you disclose involvement in illegal activities, I reserve the right to take action based on the informationprovided and my discretion. This may include sharing the information with relevant bodies such as the police. Informed Consent Examples of problems you may be experiencing that may benefit from accessing services at Willow Therapy include abuse, ad
