JENNIFER BLOOM, LCSWOutpatient Services Contract • May 21st, 2019
OUTPATIENT SERVICES CONTRACT (Updated 4/12/2021)Outpatient Services Contract • March 3rd, 2022
Welcome to the Florida MH, LLC practice. This document contains important information about Florida MH, LLC’s professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between you and Florida MH, LLC. Florida MH, LLC employs Dr. Si “Arthur” Chen Psy.D (“Dr. Chen”) as a Florida Licensed Psychologist - PY 10667 and a Maryland Licensed Psychologist #06586.
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • January 9th, 2022
Welcome to the practice of Dr. Romy Nesin. This document contains important information about my professional services and business policies, as well as your rights and responsibilities. Please read it carefully and inform me if you have any questions. This document will constitute an agreement between us once you consent and sign on the last page.
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • February 22nd, 2017
Welcome to my practice. This document contains important information about my professional services and business policies. When you sign this document, it will represent an agreement between us. Douglas Marlow, Ph.D. is a clinical psychologist licensed by the Oregon Board of Psychologist Examiners and is a member of the American Psychological Association and the Oregon Psychological Association. Dr. Marlow provides a range of psychological services including counseling, consulting, and evaluations to individuals, groups, and families in a practice that covers all ages.
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • September 23rd, 2019
This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have, so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • May 21st, 2022
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.
Outpatient Services ContractOutpatient Services Contract • November 13th, 2018
Welcome to LaTonya McCurry Counseling Services, LLC. Thank you for allowing this practice to join you on your journey to recovery. This document contains important information about my professional services and business
FULCRUM PSYCHOLOGY LLCOutpatient Services Contract • February 27th, 2020
This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.
OUTPATIENT SERVICES CONTRACT (MINORS)Outpatient Services Contract • September 17th, 2018
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • August 13th, 2018
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them. When you sign this document, it will represent an agreement between us and consent to treatment. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action which relied on the Agreement; if there are obligations imposed on me by your health insurer or in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations. In addition, if I make any changes to my business policies I will provide you with written notification of these changes prior to their implementation. I will ask you to sign a form to acknowledge receipt of such a notification at that time.
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • August 12th, 2015
Welcome to our practice. 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 new privacy protections and new 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. Please read this contract carefully and note any questions you might have so that you can discuss them with your therapist. By signing this document, it will represent an agreement between you and Parker Collins. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless we have taken action in reliance on it; eg. if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • October 17th, 2021
Welcome to my practice. This document contains important information about my professional services and business policies. When you sign this document, it will represent an agreement between us. Jessica Vincenzo is a licensed clinical social worker licensed by the Oregon State Board of Licensed Social Workers as well as the Board of Oncology Social Work and is a member of the National Association of Social Workers and Association of Oncology Social Workers and has completed the Level 3 Practicum Training in Gottman Method Couples Therapy. Jessica Vincenzo, LCSW provides a range of psychological services including counseling, consulting, and evaluations to individuals and couples in a practice that covers adults.
OUTPATIENT SERVICES CONTRACT FOR A MINOROutpatient Services Contract • July 15th, 2014
Prior to beginning treatment, it is important for you to understand my approach to child therapy and agree to some rules about your child’s confidentiality during the course of his/her treatment. The information herein is in addition to the information contained in the Patient-Therapist Agreement. Under HIPAA and the APA Ethics Code, I am legally and ethical responsible to provide you with informed consent. As we go forward, I will try to remind you of important issues as they arise.
