OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies & General Information Agreement for Psychotherapy Services • June 26th, 2022
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law.
Office Policies & General Information Agreement for Psychotherapy Services or Informed Consent for PsychotherapyOffice Policies & General Information Agreement for Psychotherapy Services • February 12th, 2018
This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
Revised 01/03/2022Office Policies & General Information Agreement for Psychotherapy Services • October 11th, 2021
This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
Office Policies & General Information Agreement for Psychotherapy ServicesOffice Policies & General Information Agreement for Psychotherapy Services • September 26th, 2021
All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (the client’s) written permission, except where disclosure is required or allowed by law.
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies & General Information Agreement for Psychotherapy Services • January 2nd, 2023
DEFINITIONS: Throughout this Agreement, the words I, Me and My refer to Russell L. Wilkie, MA, LMFT, and the words You and Your refer to the client(s).
Office Policies & General Information Agreement for Psychotherapy Services or Informed Consent for PsychotherapyOffice Policies & General Information Agreement for Psychotherapy Services • May 28th, 2016
This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
Office Policies & General Information Agreement for Psychotherapy Services or Informed Consent for PsychotherapyOffice Policies & General Information Agreement for Psychotherapy Services • July 28th, 2018
This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies & General Information Agreement for Psychotherapy Services • August 25th, 2020
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form.
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies & General Information Agreement for Psychotherapy Services • April 2nd, 2021
NOTE: This form provides you (patient) with information that is additional to that detailed in the “HIPAA Notice of Privacy Practices” form it is subject to HIPAA pre-emptive analysis.
Deborah Rubright, MSOffice Policies & General Information Agreement for Psychotherapy Services • December 30th, 2020
This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
Dr. Debra Mandel-A Professional Psychological Corporation Service Provider: Debra Mandel, Ph.D.Office Policies & General Information Agreement for Psychotherapy Services • March 3rd, 2016
This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
Office Policies & General Information Agreement for Psychotherapy Services or Informed Consent for PsychotherapyOffice Policies & General Information Agreement for Psychotherapy Services • May 27th, 2021
This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
Ginger Martire, PhD PSY21925 20688 Fourth StreetOffice Policies & General Information Agreement for Psychotherapy Services • October 16th, 2022
Office Policies & General Information Agreement for Psychotherapy Services or Informed Consent for PsychotherapyOffice Policies & General Information Agreement for Psychotherapy Services • July 4th, 2011
This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies & General Information Agreement for Psychotherapy Services • January 26th, 2022
This form provides you with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA pre-emptive analysis.
Office Policies & General Information Agreement for Psychotherapy Services or Informed Consent for PsychotherapyOffice Policies & General Information Agreement for Psychotherapy Services • November 26th, 2023
This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
Office Policies & General Information Agreement for Psychotherapy ServicesOffice Policies & General Information Agreement for Psychotherapy Services • September 23rd, 2021
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law.
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies & General Information Agreement for Psychotherapy Services • July 25th, 2016
This form provides you (patient) with information that is additional to that detailed in the Notice of Privacy Practices.
Office Policies & General Information Agreement for Psychotherapy Services Lisa Sofro Knakal, M.A. LMFT, INCOffice Policies & General Information Agreement for Psychotherapy Services • November 23rd, 2021
Payment: Payment is due at the end of each session unless other arrangements are made. Please notify me if any problem arises during the course of therapy regarding your ability to make timely payment. Returned checks are charged an additional $20.00 fee. Telephone conversations beyond 15 minutes, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged the same rate, unless indicated and agreed otherwise.
Steven David, Ph.D.Office Policies & General Information Agreement for Psychotherapy Services • February 10th, 2021
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law.
Jerry G. Soucy, Ph.D.Office Policies & General Information Agreement for Psychotherapy Services • February 25th, 2006
This form provides you (patient) with information that is additional to that detailed in the Notice of Privacy Practices.
Cindy M. Kim, MSW, LICSWOffice Policies & General Information Agreement for Psychotherapy Services • September 2nd, 2020
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 relatively new privacy protections and patient rights with regard to the use and disclosure of your protected health information used for the purposes of treatment, payment, and health care operations. In compliance with this law, I am providing you with a more detailed HIPAA Notice of Privacy Practices, which explains this in much greater detail. It is very important that you read these documents carefully. We can, and should, discuss any questions you have about this agreement and/or the attached HIPAA Notice of Privacy Practices at any time. After reviewing this information, please sign this form, which constitutes an agreement between us. You may revoke this agreement in writing at any time.
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies & General Information Agreement for Psychotherapy Services • September 16th, 2016
CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours (2 days) notice is required for re- scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies & General Information Agreement for Psychotherapy Services • February 11th, 2022
Confidentiality: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law.
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies & General Information Agreement for Psychotherapy Services • December 14th, 2018
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law.
Office Policies & General Information Agreement for Psychotherapy ServicesOffice Policies & General Information Agreement for Psychotherapy Services • March 8th, 2012
This form provides you (patient) with information that is additional to that detailed in the Notice of Privacy Practices, and it is subject to HIPAA pre-emptive analysis. (Revised 1/05) CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law.
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies & General Information Agreement for Psychotherapy Services • February 22nd, 2022
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies & General Information Agreement for Psychotherapy Services • February 3rd, 2021
NOTE: This form provides you (patient) with information that is additional to that detailed in the “HIPAA Notice of Privacy Practices” form it is subject to HIPAA pre-emptive analysis.
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies & General Information Agreement for Psychotherapy Services • December 29th, 2020
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.
Office Policies & General Information Agreement for Psychotherapy Services or Informed Consent for PsychotherapyOffice Policies & General Information Agreement for Psychotherapy Services • August 17th, 2021
This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
Deborah Rippee, M.A., LMFT Lic # LMFT104043Office Policies & General Information Agreement for Psychotherapy Services • October 6th, 2021
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form.
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICES ANGIE LEWIS, M.S.Office Policies & General Information Agreement for Psychotherapy Services • March 23rd, 2018
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law (See HIPAA Attachment).
John J. Murphy, Ph.D. Clinical Psychologist (#22783)Office Policies & General Information Agreement for Psychotherapy Services • July 8th, 2019
Confidentiality: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law.
Diane Ghiron, Psy.D.Office Policies & General Information Agreement for Psychotherapy Services • July 1st, 2014
Lisa Kaplan, MFTOffice Policies & General Information Agreement for Psychotherapy Services • May 2nd, 2014
This form provides you (patient) with information that is additional to that detailed in the Notice of Privacy Practices.
