Clack Associates, LLC. Angela R. Clack, PsyD, LPC License#37PC00323700Informed Consent for Counseling • November 13th, 2020
Welcome to my practice. This document (the Agreement) 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 new federal law that provides new privacy protections and new 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 Notice, which is attached to 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 at the end of this session. Although these documents are long and sometimes complex, it is very important that y
Melinda Siders, MA, LMFT #110318 309 W Main Street, Suite 106Informed Consent for Counseling • March 24th, 2020
California law requires licensed therapists to provide their clients with information that allows them to make informed decisions regarding their participation in therapy. This document serves as an agreement between Melinda Siders, LMFT, and any person or persons who seek therapy services from her. This document is meant to be both informative and consensual in nature and is legally binding once it has been signed and dated. Both client and therapist consent to the terms of this agreement as stated below.
