Client Information and Treatment AgreementClient Information and Treatment Agreement • September 25th, 2018
Welcome to The Child and Family Counseling Center, PLLC (CFCC). This brochure answers questions often asked about therapy and has information important for you to know before starting therapy. Please read all of it and write down any questions you have. We will discuss these when we review this information together at our initial meeting. When you have read and fully understood this brochure, please sign the consent at the end. We are happy to provide you with a copy.
CLIENT INFORMATION AND TREATMENT AGREEMENTClient Information and Treatment Agreement • July 27th, 2013
Since you are a new client, it is important that I provide you with some information about your treatment, your rights, and my office policies. Please read the following form. I will be pleased to respond to any questions you may have regarding any of this information.
CLIENT INFORMATION AND TREATMENT AGREEMENTClient Information and Treatment Agreement • February 22nd, 2010
This document (the Agreement) contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act of 1996 (HIPAA), a federal law that provides privacy protections and client 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 Notice, which is included with this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions
