ASSESSMENT & PSYCHOTHERAPY SERVICES AGREEMENTPsychotherapy Services Agreement • May 11th, 2020
Welcome to West Chester University (WCU) Community Mental Health Services (CMHS). This agreement contains important information about 1) our professional services and special conditions related to being a training site, 2) summary information about the Health Insurance Portability and Accountability Act (HIPAA) and confidentiality, 3) our communication policy, 4) our grievance procedures, and 5) our business practices. It is important that you read it carefully before our next session and ask any questions you might have when we meet again. You will receive a copy of this notice. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of Protected Health Information (PHI) for treatment, payment and health care operations. The Notice, which is attached to this agreement, explains HIPAA and its application to your PHI in greater detail. The law requires that we obtain your signature today acknowledging that we have provided you with this
Psychotherapy Services Agreement with Aimee Lim-Miller, MSW, LICSW Notice of Policies and Practices to Protect the PrivacyPsychotherapy Services Agreement • January 8th, 2021
This document contains important information about our professional services and business policies. It also contains information about our policies and practices to protect the privacy of your health information. Please read it carefully and discuss any questions you may have with me. When you sign this document, you will be stating that I provided you with this information and it will represent an agreement between us.
Psychotherapy Services AgreementPsychotherapy Services Agreement • May 8th, 2022
All psychotherapy services are provided by Dr. Jonathan Stillerman, a licensed psychologist in the District of Columbia. All sessions are conducted in-person; if it is unsafe to do so, sessions will take place virtually through Zoom or by phone.
PSYCHOTHERAPY SERVICES AGREEMENTPsychotherapy Services Agreement • September 11th, 2017
Welcome to West Chester University (WCU) Community Mental Health Services (Clinic). This agreement contains important information about 1) our professional services and special conditions related to being a training clinic, 2) summary information about the Health Insurance Portability and Accountability Act (HIPAA) and confidentiality, and 3) our clinic business practices. It is important that you read it carefully before our next session and ask any questions you might have when we meet again. You will be given a copy to take home. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of Protected Health Information (PHI) for treatment, payment and health care operations. The Notice, which is attached to this agreement, explains HIPAA and its application to your PHI in greater detail. The law requires that we obtain your signature today acknowledging that we have provided you with this information. In addition, when you sign this doc
Sari Chait, Ph.D. Licensed PsychologistPsychotherapy Services Agreement • August 20th, 2020
Welcome to the Behavior Health and Wellness Center, LLC! This document contains important information about my professional services and business policies. Please read it carefully and let me know if you have any questions. We can discuss any questions you have prior to signing the document. When you sign this document, it will represent an agreement between us.
Psychotherapy Services AgreementPsychotherapy Services Agreement • November 6th, 2020
Welcome to our psychotherapy practice! This document (the Agreement) contains important legal information about our professional services and office 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 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 by the end of your first session. Although these are long documents, it is very important that you read
PSYCHOTHERAPY SERVICES AGREEMENTPsychotherapy Services Agreement • January 17th, 2024
This document (the Agreement) contains 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). 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, 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 important that you read them carefully. We can discuss any questions you have about the procedures. When you sign this document, it will also represent an agreement between u
SOFIA R. TUCHAPSKY, LMHC, NCC, CCMHCPsychotherapy Services Agreement • December 5th, 2022
This information is provided concerning my professional practice and business policies. Please read it carefully and raise any questions you may have with me, so that we can discuss them. When you sign this document, it will represent an agreement between us.
Psychotherapy Services AgreementPsychotherapy Services Agreement • November 9th, 2020
Welcome to my practice. Therapy is a relationship that works best when there is clear communication and transparency between therapist and client. This document sets a frame to establish mutual expectations for how we will work together. Having a clearly defined professional relationship fosters safety to assist you in moving forward with your goals.
Psychotherapy Services AgreementPsychotherapy Services Agreement • January 16th, 2021
This agreement contains important information about my professional services and business policies. Please read it carefully and discuss with me any questions you may have at your first meeting. When you sign this document, it will represent an agreement between us. You may revoke this agreement in writing at any time.
Psychotherapy Services AgreementPsychotherapy Services Agreement • December 29th, 2022
This consent form and therapy agreement describes important information about the professional services and business policies of your provider at Calm Harbors Counseling. Your signature on this document represents an agreement between you (the client), your provider, and Calm Harbors Counseling. It is important to discuss any questions you may have with your provider. Please be aware may revoke the agreement in writing at any time.
Psychotherapy Services AgreementPsychotherapy Services Agreement • August 29th, 2020
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully. We can discuss any questions you might have at our next meeting. When you book an appointment, this document will represent an agreement between us.
Psychotherapy Services AgreementPsychotherapy Services Agreement • July 23rd, 2019
Welcome to Know. Grow. Heal., Inc. This document contains important information about my professional services and business polices. Please read it carefully and discuss any questions you may have with me. When you sign this document, it will also represent an agreement between us.
PSYCHOTHERAPY SERVICES AGREEMENT & CONSENT TO TREATMENTPsychotherapy Services Agreement • December 7th, 2015
Welcome to my practice. This document contains important information about my professional services and business policies. Please read this document carefully and note 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.
Chloe Buckley, Ph.D, LLCPsychotherapy Services Agreement • November 3rd, 2022
Welcome. This document provides important information about my professional services and business policies. Please read it carefully and ask any questions you might have. Signing this document represents an agreement between us that was entered into with full informed consent.
PSYCHOTHERAPY SERVICES AGREEMENTPsychotherapy Services Agreement • August 29th, 2020
Welcome to the therapeutic practice of Lynn Harris Luetgers, LMFT. This document contains important informa- tion about my professional services and business policies. It also contains information about your health informa- tion privacy rights. Please read it carefully and let me know if you have any questions or concerns. Signing this document represents a binding agreement between us.
TACOMA OFFICE SILVERDALE OFFICEPsychotherapy Services Agreement • January 2nd, 2022
Welcome to the Northwest Relationships. This document contains important information about our professional services and business policies. It also contains information about our policies and practices to protect the privacy of your health information. Please read it carefully and discuss any questions you may have with your therapist.
Jennifer L. Abel, Ph.D.Psychotherapy Services Agreement • July 27th, 2023
Welcome to my practice. This document (the Agreement) contains information about my professional services, business policies and the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and 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) the law requires that I obtain your signature acknowledging that I have given it to you.
PSYCHOTHERAPY SERVICES AGREEMENTPsychotherapy Services Agreement • October 9th, 2020
Psychotherapy is a complex process. My process varies depending on your personality and mine and the relationship that we create. I will be relying on many different therapeutic approaches as we address the issues and concerns that you bring to the session. The process of psychotherapy is different from other medical services. It calls for active effort on your part. For therapy to be most successful, you will need to be engaged with the process both during our sessions and outside of the therapy hour.
NORTHWEST RELATIONSHIPS, PLLCPsychotherapy Services Agreement • July 14th, 2020
Psychotherapy Services AgreementPsychotherapy Services Agreement • May 23rd, 2018
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully. We can discuss any questions you might have at our next meeting. When you book an appointment, this document will represent an agreement between us.
Psychotherapy Services AgreementPsychotherapy Services Agreement • January 2nd, 2017
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 for 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 accompanies this agreement, explains HIPAA and its application to your personal health information in detail. As required by law, on the last page of this agreement you are asked for your signature acknowledging that I have provided you with this information. When you sign this document, it will represent an agreement between us. You may revoke this Agreement i
COUNSELLING & PSYCHOTHERAPY SERVICES AGREEMENTPsychotherapy Services Agreement • March 7th, 2024
Life is full of challenges, and even though we can not avoid these challenges, there is no rule stating we must go through them alone. As with any new journey, it can be helpful to know what to expect. This document outlines some important information about my professional services and business policies. Please read it carefully and discuss any questions that arise as this document acts as an agreement between you as the client and myself as the therapist of Mindful Perspective Counselling Inc.
Psychotherapy Services AgreementPsychotherapy Services Agreement • January 13th, 2016
This agreement contains important information about my professional services and business policies. Please read it carefully and discuss with me any questions you may have at your first meeting. When you sign this document, it will represent an agreement between us. You may revoke this agreement in writing at any time.
PSYCHOTHERAPY SERVICES AGREEMENTPsychotherapy Services Agreement • May 2nd, 2020
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 new privacy protections and new patient 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. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you
PSYCHOTHERAPY SERVICES AGREEMENTPsychotherapy Services Agreement • May 4th, 2009
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 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. HIPPA requires that I provide you with a Notice of Privacy Practices. The Notice (find a copy in my waiting room) explains HIPAA as it applies to your 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 complex, it is important that you read them carefully. We can discuss any questions you have about procedures. We can discuss any questions you have after you have read the information. When you sign this document,
James A. Purvis, Ph.D. Psychotherapy Services AgreementPsychotherapy Services Agreement • October 18th, 2021
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems that you are experiencing. There are many different methods that I may use to deal with the issues that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things that we talk about both during our sessions and at home.
Lori J. Warner, Ph.D.Psychotherapy Services Agreement • December 11th, 2020
ContractPsychotherapy Services Agreement • February 26th, 2014
Hello and welcome. This policy is an opportunity to acquaint you with information relevant to treatment, confidentiality, services and business policies. It also contains information about my policies and practices to protect the privacy of your health information. Please read it carefully and discuss any questions you may have with me. When you sign this document, you will be stating that I provided you with this information and it will represent an agreement between us.
PSYCHOTHERAPY SERVICES AGREEMENTPsychotherapy Services Agreement • January 17th, 2024
This document (the Agreement) contains 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). 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, 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 important that you read them carefully. We can discuss any questions you have about the procedures. When you sign this document, it will also represent an agreement between u
PSYCHOTHERAPY SERVICES AGREEMENTPsychotherapy Services Agreement • February 23rd, 2017
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 new federal law that provides new privacy protections and new patient 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. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions
