PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENTPsychotherapist-Client Services Agreement • March 30th, 2024
This document contains important information about my professional services and business policies. When you sign this information, it represents an agreement between us. You may revoke this Agreement in writing at any time. This document also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protection and patient rights about the use and disclosure of Protected Health Information (PHI). HIPAA requires that I provide you with a Notice of Privacy Practices for using and disclosing PHI for the purposes of treatment, payment, and health care operations. The required Notice is attached to this agreement. The law requires that I obtain your signature acknowledging that I have provided you with this information.
Eric stephen jannazzo, Ph.D. Licensed PsychologistPsychotherapist-Client Services Agreement • March 31st, 2024
Paula Helsby, MA, MS, MA, NCCPsychotherapist-Client Services Agreement • May 18th, 2011
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 protection 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. HIPPA 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 HIPPAA 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 yo
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENTPsychotherapist-Client Services Agreement • November 13th, 2019
Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/EAP in order to process the claims. I have no control or knowledge over what insurance companies do with the information.
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENTPsychotherapist-Client Services Agreement • May 19th, 2014
Welcome. 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 new 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 purposes 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 we have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can di
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT AND OFFICE POLICIESPsychotherapist-Client Services Agreement • March 20th, 2023
Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies that is additional to that detailed in the Notice of Privacy Practices. 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 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. 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
DAVID J. LUTZ, PH.D.Psychotherapist-Client Services Agreement • December 10th, 2021
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 federal law that provides privacy protections and 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. 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. Although these documents are long and sometimes complex, it is important that you read them carefully. We can discuss any qu
Psychotherapist-Client Services AgreementPsychotherapist-Client Services Agreement • April 17th, 2020
This form has three purposes. First, it tells you about my procedures and policies concerning important aspects of your psychotherapy. Please let me know if you have concerns about any of these policies. Your first visit will help me get a general understanding of your situation in order to determine how I might best help you. Because I want you to participate actively in planning your counseling, don’t hesitate to ask questions.
Anderson, Arnold and Partners, L.L.P. Psychological and Counseling Services PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENTPsychotherapist-Client Services Agreement • July 17th, 2018
Welcome to Anderson, Arnold & Partners, L.L.P. We are pleased that you chose our practice for services for yourself or your child. As we welcome you to our office, we would like to share with you some information about our professional services and business policies. Although this document is long and sometimes complex, it is very important to review this information carefully so you may be fully informed about the nature of mental health services and business practices provided at our office. We are happy to discuss any questions you have about this information as we get started and as treatment progresses. At the end of this document, we will ask for your signature to verify that you have reviewed the information that follows and given consent.
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENTPsychotherapist-Client Services Agreement • May 13th, 2022
Welcome to my practice. 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 new 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.
DAVID J. LUTZ, PH.D.Psychotherapist-Client Services Agreement • December 19th, 2017
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 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. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENTPsychotherapist-Client Services Agreement • March 23rd, 2016
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 new 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. 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. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you have about
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENTPsychotherapist-Client Services Agreement • October 28th, 2023
This agreement contains important information about the professional services and business policies at Behavioral Wellness Center of South Florida, LLC.
Austin, Texas, 78704Psychotherapist-Client Services Agreement • January 14th, 2023
Welcome to my practice. This document contains important information about my professional services and business policies. It is important that you read them carefully, and bring any questions you may have so that we can discuss them at our next session. When you sign this document, it will represent an agreement between us. You may revoke this agreement in writing at any time.
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENTPsychotherapist-Client Services Agreement • November 27th, 2023
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 federal law that provides privacy protections and 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. 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 available on our website or in the waiting areas of our office, 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 i
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENTPsychotherapist-Client Services Agreement • April 13th, 2023
Welcome to this practice. This document (the Agreement) 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 client rights with regard to the use and disclosure of Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we 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 we obtain your signature acknowledging that we 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 you read them
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENTPsychotherapist-Client Services Agreement • March 9th, 2016
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 federal law that provides privacy protections and 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. The Notice, which is attached to this Agreement, explains HIPAA and its application to your PHI in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, it is important that you read them carefully. We can discuss any questions you have about the procedures. When you sign this document, it wil
General Information & Psychotherapist-Client Services AgreementPsychotherapist-Client Services Agreement • December 19th, 2009
Welcome to my practice. 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 new federal law that provides new privacy protections and new client rights with regard to the use and disclosure of your Protected Health Information (PHI). HIPAA requires that I provide you with a Notice of Privacy Practices, which accompanies this document. The law requires that I obtain your signature acknowledging that I have provided you with this information and that you agree/consent to let me use your information as specified in the Notice. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have ta
Psychotherapist-‐Client Services AgreementPsychotherapist-Client Services Agreement • September 28th, 2021
This form has three purposes. First, it tells you about my procedures and policies concerning important aspects of your psychotherapy. Please let me know if you have concerns about any of these policies. Your first visit will help me get a general understanding of your situation in order to determine how I might best help you. Because I want you to participate actively in planning your counseling, don’t hesitate to ask questions.
InnerVision Therapy, LLC.Psychotherapist-Client Services Agreement • February 9th, 2017
This Agreement has three purposes. First, it tells you about procedures and policies concerning important aspects of your psychotherapy. Please inform your therapist if you have concerns about any of these policies. Your first visit will help your therapist get a general understanding of your situation in order to determine how you might be best helped. Because it is expected that you participate in planning counseling, do not hesitate to ask questions.
Jennifer Sutherland, M.S, Ed.S. Licensed Psychological Practitioner Cell 859-433-9526 Fax 866-266-0695 jscpsychservice@gmail.comPsychotherapist-Client Services Agreement • March 19th, 2014
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENTPsychotherapist-Client Services Agreement • May 6th, 2019
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand psychotherapy has also been shown to have many benefits. Therapy often leads to better
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT DISCLOSURE STATEMENTPsychotherapist-Client Services Agreement • January 12th, 2022
Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. This document also contains summary information about the Health Insurance Portability and Accountability Act (HIPPA), a federal law that provides privacy protections and client rights regarding the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. In addition, HIPPA requires that I provide you with a Notice of Privacy Practices (the Notice) regarding formal disclosure of PHI for treatment, payment, and health care operations. The Notice, which is attached to this Agreement, explains HIPPA and its application to your personal health information in formal detail. The law requires that, as soon as possible (first or second session), I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes comp
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENTPsychotherapist-Client Services Agreement • September 18th, 2024
Welcome. 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 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 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 you read them carefully before our next session. We can d
Alive and Well Center for Integrative Psychotherapy 6105 E. Grant Road Christina Romano, M.Ed., LPC, LISAC Tucson, AZ 85712Psychotherapist-Client Services Agreement • December 9th, 2015
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENTPsychotherapist-Client Services Agreement • July 5th, 2020
Welcome to my practice. This 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 federal law that provides privacy protections and client rights with regard to the use and disclosure of your Protected Health Information (PHI). 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 law requires that I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocati
Psychotherapist-Client Services AgreementPsychotherapist-Client Services Agreement • July 27th, 2020
Welcome to my office and practice. This document (the Agreement) contains important information about my professional services and business policies, all of which conform not only to the Health Insurance Portability and Accountability Act (HIPAA), but also to the laws of the State of Georgia. It also contains summary information about 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 also 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, as your individual psychotherapist, have provided
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT (PATIENT 14 YEARS OR OLDER)Psychotherapist-Client Services Agreement • May 29th, 2020
Welcome and thank you for choosing us. Psychotherapy varies depending on the personal- ities of the provider and patient, and the problems you are experiencing. There are many different methods your therapist may use to address the issues that you are experiencing.
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENTPsychotherapist-Client Services Agreement • March 19th, 2020
Welcome to the Central DuPage Pastoral Counseling Center. 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 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 we provide you with a Notice of Privacy Practices 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 we obtain your signature acknowledging that I have provided you with this information at the first session. Although these documents are long and sometimes complex, it is very important that
LISA K. SCHKLOVEN, LCSW-C, LLCPsychotherapist - Client Services Agreement • November 25th, 2019
This document (Agreement) outlines the professional services and business policies of Lisa K. Schkloven, LCSW-C. My policies are in accordance with the 2010 Federal Health and Insurance Portability and Accountability Act (HIPPA).
Richard J. Aucoin, Ph.D.Psychotherapist-Client Services Agreement • March 2nd, 2022
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.
Austin, Texas, 78704Psychotherapist-Client Services Agreement • September 9th, 2021
Welcome to my practice. This contains important information about my professional services and business policies. Read them carefully, and bring any questions you may have so that we can discuss them at our next session. When you sign this document, it will represent an agreement between us. You may revoke this agreement in writing at any time.
Dragonfly CounselingPsychotherapist-Client Services Agreement • February 12th, 2022
This form has been developed to provide you with information about psychotherapy procedures and practices. It contains information about the Health Insurance Portability and Accountability Act (HIPPA) Privacy rule, and some professional ethical codes relevant to therapy. You may choose to revoke this agreement at any time, which will mean you no longer consent to treatment, however, some parts may still be enforced.
Dragonfly CounselingPsychotherapist-Client Services Agreement • February 6th, 2022
This form has been developed to provide you with information about psychotherapy procedures and practices. It contains information about the Health Insurance Portability and Accountability Act (HIPPA) Privacy rule, and some professional ethical codes relevant to therapy. You may choose to revoke this agreement at any time, which will mean you no longer consent to treatment, however, some parts may still be enforced.
PsychotherapistClient Services AgreementPsychotherapist-Client Services Agreement • May 31st, 2021
This form has three purposes. First, it tells you about our procedures and policies concerning important aspects of your psychotherapy. Please let us know if you have concerns about any of these policies. Your first visit will help us get a general understanding of your situation in order to determine how we might best help you. Because we want you to participate actively in planning your counseling, don’t hesitate to ask questions.
