Informed Consent & Service AgreementInformed Consent & Service Agreement • July 13th, 2021
We are happy that you have chosen Biblical Counseling at Batesville Christian Church to provide insight and encouragement during this time in your life. Every effort will be made to ensure that your experience here is beneficial. Your counseling will be provided by Shirley Hunter who is a certified biblical counselor. She is a member of The Association of Certified Biblical Counselors (ACBC) and has helped over 300 clients process and overcome difficult circumstances using God’s word as a guide and reference.
Informed Consent Service AgreementInformed Consent Service Agreement • March 9th, 2021
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 about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations.
INFORMED CONSENT SERVICE AGREEMENTInformed Consent Service Agreement • January 6th, 2020
Scope of Services The staff of Lumina Counseling Assoc. is comprised of Michelle Chiaramonte MA, LCSW providing outpatient psychotherapy services in an office setting.
Donna Zinn LCSW LLC 600 N. Weinbach Ave. Suite 730Informed Consent Service Agreement • April 28th, 2020
Informed Consent Service AgreementInformed Consent Service Agreement • February 15th, 2020
Welcome to Blackburn Counseling. 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 about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations.
Consent: Informed Consent /Service AgreementInformed Consent / Service Agreement • March 22nd, 2024
Welcome to Mid Cities Counseling Center, PLLC. This document contains important information about our 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 about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations.
NFORMED CONSENT SERVICE AGREEMENTInformed Consent Service Agreement • February 28th, 2022
( Nedra Cannon and Associate- DBA). 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 about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations.
Informed Consent Service AgreementInformed Consent Service Agreement • September 22nd, 2021
Welcome to [YOUR PRACTICE NAME HERE]. 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 about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations.
12059 Wilderness Trail Live Oak, TX 78233 210-452-6416Informed Consent & Service Agreement • June 11th, 2014
This form represents an Informed Consent and Service Agreement (the “document”) between the client and the counselor and contains important information regarding the professional services and business policies of the counselor. Please read it carefully. I will be happy to discuss any or all of these policies in greater detail with you and answer any questions. Prior to initiating services, you will be required to sign the last page of this document and return it to me, which will indicate you have read and understand its contents. This document is subject to amendment upon notice, and you will be informed of any changes and be given an opportunity to review and approve of such changes. You may request a copy of this agreement for your records.
Northern New Jersey Therapy Cara L. McCloud, LCSWInformed Consent/Service Agreement • November 24th, 2020
This document contains important information about my professional services. Read each item below and initial in the space provided if you understand each item and agree to following. Once you sign this document, it will serve as an agreement between us. A parent or guardian of a Patient under the age of 18 must also read and understand each item before signing the agreement. Do not sign this agreement if there is anything that you do not understand about the information you have received or have not discussed at time of intake. Should you choose, you may revoke your consent for treatment at any time. In addition, this agreement will expire on termination of treatment and after all claims for treatment have been satisfied. Please read carefully and discuss with me any questions before signing and returning the copy
