Counseling to InspireAgreement for Service / Informed Consent • February 24th, 2022
Martha Perez-Quintanilla, AMFT Associate Marriage Family Therapist #116547Agreement for Service / Informed Consent • July 22nd, 2024
This Agreement is intended to provide [name of patient] (herein “Patient”) with important information regarding the practices, policies and procedures of Martha Perez-Quintanilla, Associate Marriage Family Therapist (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. The name of this practice is Campbell Teen & Family Therapy and the individual therapist that operates this practice is Ingrid Higgins, MFT (LMFT #43950). Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
Rudi Lion, MA, MFT Lic.# MFT 48741Agreement for Service / Informed Consent • June 30th, 2022
This Agreement is intended to provide (herein “Patient”) with important information regarding the practices, polices and procedures of Rudi Lion (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
Jim Rutherford, M.S. Licensed Marriage and Family Therapist LIC #MFC 42435Agreement for Service / Informed Consent • September 18th, 2024
This Agreement is intended to provide you with important information regarding my practices, polices and procedures, and to clarify the terms of the professional therapeutic relationship between the Client and Therapist. Any questions or concerns regarding the contents of this Agreement should be discussed with me prior to signing it.
VINDER LALLIAN, MA, LMFTAgreement for Service/Informed Consent • July 18th, 2016
This agreement is intended to provide [name of client] (herein “client”)with important information regarding the practices, policies and procedures of Vinder Lallian, LMFT and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns regarding the contents of this Agreement should be discussed prior to signing it.
Agr e e m e nt For Ser v i c e /Inf or me d Cons e ntAgreement for Service/ Informed Consent • July 26th, 2023
Welcome to my practice. This agreement is intended to provide you with important information about my professional services and business policies. Debra Sloss. LMFT will herein be referred to as “Therapist” and you will be referred to as “Client.” Please read this document carefully and bring any questions or concerns you have so that we can discuss those at our first meeting.
Ann Palik, MA, MFTAgreement for Service / Informed Consent • October 8th, 2021
This Agreement is intended to provide (herein “Client”) with important information about the practices and policies of Ann Palik, MA, MFT (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns about the contents of this Agreement should be discussed with Therapist prior to signing it.
Devorah Rodgers, M.A. Marriage and Family Therapist #42720 566 S. San Vicente Blvd., Suite 203 Los Angeles, CA 90048Agreement for Service / Informed Consent • May 16th, 2024
This Agreement is intended to provide the client (herein “Client”) with important information regarding the practices, polices and procedures of Devorah Rodgers (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
AGREEMENT FOR SERVICE/INFORMED CONSENTAgreement for Service/Informed Consent • November 15th, 2019
This Agreement is intended to provide [client name] (herein referred to as Client) with important information regarding the practices, policies and procedures of Lorelei A. O’Neill, Licensed Marriage & Family Therapist Professional Corporation (herein referred to as the “Therapist”), and to clarify the terms of the professional therapeutic relationship between the Therapist and the Client. Any questions or concerns regarding the contents of this Agreement should be discussed with the Therapist prior to signing it.
AGREEMENT FOR SERVICE / INFORMED CONSENTAgreement for Service / Informed Consent • December 28th, 2022
This Agreement is intended to provide (herein “Patient”) with important information regarding the practices, policies and procedures of Deborah Moyer, LMFT (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
Dr. Renee M. Winters, PhD, MFT Licensed Marriage and Family Therapist License #51788Agreement for Service / Informed Consent • July 2nd, 2021
Eileen Drapiza-Dornan, M.A., LMFTAgreement for Service / Informed Consent • May 22nd, 2015
This Agreement is intended to provide [name of patient/s] (herein “Patient”) with important information regarding the practices, polices and procedures of Eileen Dapiza-Dornan, LMFT (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
Licensed Marriage and Family Therapist #79098Agreement for Service / Informed Consent • March 18th, 2021
This Agreement is intended to provide [name of patient] (herein “Patient”) with important information regarding the practices, policies and procedures of Susan Valkenaar (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
Michael G. Quirke M.A. Licensed Marriage and Family TherapistAgreement for Service / Informed Consent • December 28th, 2021
Tina KopkoAgreement for Service / Informed Consent • August 5th, 2021
This Agreement is intended to provide [name of client] (herein “Client”) with important information regarding the practices, policies and procedures of Tina Kopko (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
Quiet Waters CounselingAgreement for Service / Informed Consent • July 2nd, 2015
This Agreement is intended to provide [name of patient] (herein “Patient”) with important information regarding the practices, polices and procedures of Anthony Q. Liu, MFT (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
AGREEMENT FOR SERVICE / INFORMED CONSENTAgreement for Service / Informed Consent • September 24th, 2013
This Agreement is intended to provide [name of patient] ________________________________ (herein “Patient”) with important information regarding the practices, polices and procedures of Michelle Dadoun (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
MELANIE DAVIS, LCSWAgreement for Service / Informed Consent • July 2nd, 2014
This Agreement is intended to provide [name of client] (herein “Client”) with important information regarding the practices, policies and procedures of Melanie Davis, LCSW (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
AGREEMENT FOR SERVICE / INFORMED CONSENTAgreement for Service / Informed Consent • December 17th, 2020
This Agreement is intended to provide (herein “Patient”) with important information regarding the practices, policies and procedures of LaDonna Parker, LMFT #44178 (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
AGREEMENT FOR SERVICE / INFORMED CONSENTAgreement for Service / Informed Consent • May 19th, 2023
This Agreement is intended to provide (herein “Client”) with important information regarding the practices, polices and procedures of Rainer Geissler, MA, LMFT, (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
AGREEMENT FOR SERVICE / INFORMED CONSENTAgreement for Service / Informed Consent • November 19th, 2019
(herein “Client”) with important information regarding the practices, policies and procedures of Michael Miller (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
License #83383Agreement for Service / Informed Consent • February 14th, 2015
This Agreement is intended to provide (herein “Patient”) with important information regarding the practices, polices and procedures of Mary L. Hill, LMFT (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
AGREEMENT FOR SERVICE / INFORMED CONSENTAgreement for Service / Informed Consent • May 14th, 2022
with important information regarding the practices, polices and procedures of Rainer Geissler, MA, LMFT, (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
CA Licensed Marriage and Family Therapist www.lanagarvin.comAgreement for Service/Informed Consent • October 1st, 2018
This agreement is intended to provide [name of client] (herein “client”)with important information regarding the practices, policies and procedures of Lana Garvin, LMFT and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns regarding the contents of this Agreement should be discussed prior to signing it.
Agreement For Service / Informed ConsentAgreement for Service / Informed Consent • December 10th, 2019
This agreement is intended to provide (herein referred to as “Patient”) with important information regarding the practices, policies, and procedures of Mitchell J. Cohen, L.M.F.T. (herein referred to as “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns regarding the contents of this agreement should be discussed with Therapist prior to signing it.
Agreement For Service/Informed ConsentAgreement for Service/Informed Consent • February 2nd, 2022
Welcome to my practice. I am a licensed Marriage and Family Therapist. I am trained to provide psychotherapy to adults, couples, adolecents, and families. The Code of Ethics in my profession requires that I make you aware of specific policies. If you have any questions after reading this form, please bring them to my attention.
Sheryl A. Isaacs MS, LMFT Licensed Marriage and Family Therapist #92577 5523 Scotts Valley Drive, Scotts Valley, CA 95066Agreement for Service / Informed Consent • June 30th, 2024
The therapeutic relationship is unique in that it is highly personal and at the same time a contractual agreement. It is important that we have a clear understanding about how our relationship will work, and what each of us can expect. Please read this consent thoroughly and discuss any questions that you have. Please indicate you have reviewed this information by signing or filling in the checkbox if read electronically.
AGREEMENT FOR SERVICE / INFORMED CONSENTAgreement for Service / Informed Consent • June 12th, 2023
This Agreement is intended to provide (herein “Client”) with important information regarding the practices, polices and procedures of Ross Bryan MA MFT (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
AGREEMENT FOR SERVICE / INFORMED CONSENTAgreement for Service / Informed Consent • October 14th, 2015
regarding the practices, policies and procedures of Ann Landers, Therapist, and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
Minou Mayer, MA, LMFTAgreement for Service / Informed Consent • May 15th, 2015
This Agreement is intended to provide (herein “Patient”) with important information regarding the practices, policies and procedures of Minou Mayer, LMFT (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
AGREEMENT FOR SERVICE / INFORMED CONSENTAgreement for Service / Informed Consent • October 29th, 2016
This Agreement is intended to provide (herein “Client”) with important information regarding the practices, polices and procedures of Gregory Burns (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
Ole von Frausing-Borch, RN, MSEd, MFT = Counseling and Psychotherapy = Licensed Marriage and Family Therapist License # 8963 AGREEMENT FOR SERVICE / INFORMED CONSENTAgreement for Service / Informed Consent • March 22nd, 2016
(herein “Client”) with important information regarding the practices, policies and procedures of Ole von Frausing-Borch, LMFT (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
Ann Palik, MA, LMFTAgreement for Service / Informed Consent • April 24th, 2021
This Agreement is intended to provide (herein “Client”) with important information about the practices and policies of Ann Palik, MA, LMFT (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns about the contents of this Agreement should be discussed with Therapist prior to signing it.
Lisa Locke, M.SAgreement for Service / Informed Consent • May 9th, 2017
You are seeing me for couples or family therapy, I consider your relationship to be the client/patient. This Agreement is intended to provide [name of patient] and [name of patient] (herein “Patient”) with important information regarding the practices, policies and procedures of Lisa Locke, LMFT (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
Counseling to Inspire, Inc.Agreement for Service / Informed Consent • August 20th, 2021
