AGREEMENT FOR PSYCHOTHERAPY SERVICESAgreement for Psychotherapy Services • April 18th, 2016 • California
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law.
AGREEMENT FOR PSYCHOTHERAPY SERVICESAgreement for Psychotherapy Services • July 15th, 2008
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (patient’s) written permission, except where disclosure is required by law.
AGREEMENT FOR PSYCHOTHERAPY SERVICESAgreement for Psychotherapy Services • August 28th, 2020
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law.
Quail Hollow Psychotherapy PLLCAgreement for Psychotherapy Services • August 8th, 2018
Welcome to my practice: This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment, and health care operations. The law requires that I obtain your signature acknowledging that I have provided you with this information. Please read it carefully and jot down any questions you might have so that we can discuss them at our first appointment. When you sign this document, it will represent an agreement between us.
AGREEMENT FOR PSYCHOTHERAPY SERVICESAgreement for Psychotherapy Services • February 21st, 2006
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client's) written permission, except where disclosure is required by law.
DR. LIZ ZEDAgreement for Psychotherapy Services • November 13th, 2020
This form provides you (patient) with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA pre-emptive analysis.
SHANNON LERACH, PH.D.Agreement for Psychotherapy Services • February 24th, 2023
Welcome to my practice and thank you for the confidence in me that your being here implies. Given the nature of my profession - providing psychotherapeutic treatment, assessment and consultation - it is important that you have a good sense of who I am and how I work. I ask that you review this manual to help us be as clear as possible as to the nature and expectations of our working together. Please do not hesitate at any time to ask about any portion of the information which seems unclear or confusing, or if you have any other questions.
