Inner Connections, LLCConsent to Treatment Agreement • October 23rd, 2020
This document contains information about the services and policies of Inner Connections, LLC. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and new patient rights regarding the use and disclosure of Protected Health Information (PHI) used for treatment, payment, and health care operations. Please read and initial each section and sign the signature page at the end. Before you sign the signature page at the end of this document, we can discuss any questions you have about the policies and procedures described herein. This document also represents an agreement between you and your therapist. You may revoke this Agreement in writing at any time.
ContractConsent to Treatment Agreement • August 23rd, 2021
Consent to Treatment and Conditions of Service: As either the Parent, or authorized agent or legal representative of the Patient, I consent and agree to the terms and conditions of this agreement. I make the following consents, understandings, and agreements on my own behalf.
Child & Family Psychological ServicesConsent to Treatment Agreement • February 24th, 2022
Consent to Treatment, Privacy Practices, and Payment Policies Agreement Client Name (please print): Date of Birth: Chart #: If not self, state relationship to client: I am voluntarily choosing to enter in to treatment at Child & Family Psychological Services , hereafter referred to as the Organization, and hereby acknowledge that I am over eighteen (18) years of age or am the parent/legal guardian of the child/individual, of sound mind and competent to consent to treatment. Furthermore, I consent to have treatment provided by a contractual psychiatrist, psychologist, social worker, counselor, therapist, or intern in collaboration with the Organization’s Medical Director. I understand that I will be responsible for participating in the development of my own treatment plan.I may terminate, or request a change in, the professional treating me at any time. I understand that it is my right and responsibility to voice any concerns, objections, or doubts I may have regarding the course of tr
CONSENT TO TREATMENT AGREEMENTConsent to Treatment Agreement • July 8th, 2017
This document represents an agreement between you and your therapist. You may revoke this Agreement in writing at any time.
Agreement Regarding Consent to Treatment, Polices, Services & FeesConsent to Treatment Agreement • January 4th, 2017
Please keep in mind that I do not accept insurance. You are responsible for paying all fees. I can, upon request provide you with a detailed invoice every month that you can submit to your insurance company for reimbursement.
CONSENT TO TREATMENT AGREEMENTConsent to Treatment Agreement • December 7th, 2015
Agreement and Consent to TreatmentConsent to Treatment Agreement • December 20th, 2021
signature below indicates that I have read and discussed the agreement; it does not indicate that I am waiving any of my rights. I understand that any of the points mentioned can be discussed and may be open to change. If at any time during the services I receive, I have questions about any of the subjects discussed on the Policies and Procedures document, this document, or the HIPAA Notice of Privacy document, I can talk with my provider about them, and he/she will do their best to answer them.
McLaren Bariatric & Metabolic InstituteConsent to Treatment Agreement • July 29th, 2013
Consent to Treatment AgreementConsent to Treatment Agreement • February 14th, 2017
CONSENT TO TREAT/ AGREEMENT FOR THERAPY SERVICES/ OFFICE PROCEDURESConsent to Treatment Agreement • April 9th, 2019
Welcome to Live Happy Counseling Services, LLC. This document contains important information about Live Happy Counseling, LLC professional services and business policies. We are governed by various laws and regulations and by the ethics codes of our profession. The ethic code requires that we make you aware of these office polices and how the procedures might affect you. Please take time to read thoroughly and have any questions ready to discuss with your clinician.
John R. “Jack” Steel, M.D. FACROConsent to Treatment Agreement • December 3rd, 2015
