AGREEMENT FOR SERVICE / INFORMED CONSENTPsychotherapy Services Agreement • February 11th, 2023
Psychotherapy has both benefits and risks. The risks may include experiencing uncomfortable feelings such as sadness or anger. It often requires discussing difficult aspects of your life. The majority of individuals who participate in therapy benefit from the experience. Therapy often leads to a significant reduction in feelings of distress, better relationships, and resolutions of specific problems.
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.
AGREEMENT FOR PSYCHOTHERAPY SERVICES/ INFORMED CONSENTPsychotherapy Services Agreement • March 18th, 2020
This document contains important information about our professional services and business policies. Although these documents are long and sometimes complex, it is very important that you read them carefully. When you sign this document, it will also represent an agreement between us and become a part of your electronic medical record. You may revoke this Agreement in writing at any time. That revocation will be binding on us (and our clinic) unless we have taken action in reliance on it; if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.
PSYCHOTHERAPY SERVICES AGREEMENT FOR ADOLESCENTSPsychotherapy Services Agreement • May 30th, 2022
Welcome to my practice. This document sets a frame to clarify how I work with adolescents and their families. Having clearly outlined practices fosters safety and trust in moving forward with your goals.
AGREEMENT FOR PSYCHOTHERAPY SERVICES/ INFORMED CONSENTPsychotherapy Services Agreement • February 19th, 2020
This document contains important information about our professional services and business policies. Although these documents are long and sometimes complex, it is very important that you read them carefully. When you sign this document, it will also represent an agreement between us and become a part of your electronic medical record. You may revoke this Agreement in writing at any time. That revocation will be binding on us (and our clinic) unless we have taken action in reliance on it; if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.
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
Agreement for Psychotherapy ServicesPsychotherapy Services Agreement • October 27th, 2022
In order to authorize mental health treatment for your child, you must have either sole or joint legal custody of your child. If you are separated or divorced from the other parent of your child, please notify me immediately. I will ask you to provide me with a copy of the most recent custody decree that establishes custody rights of you and the other parent or otherwise demonstrates that you have the right to authorize treatment for your child.
AGREEMENT AND CONSENT FOR PSYCHOTHERAPY SERVICESPsychotherapy Services Agreement • October 18th, 2021
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
PCSPsychotherapy Services Agreement • January 3rd, 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
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
Mary Jane DeWolf-Smith, RN, PHN, MA, LMFTPsychotherapy Services Agreement • January 9th, 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 the client’s written permission, except where disclosure is required by law or professional ethics. In couple and family therapy, confidentiality and privilege do not apply between the couple or among family member clients. In this case I will use my clinical judgment when revealing any information to the couple or family member clients. Unless otherwise required by law (see below) I will not release records to any outside party without written authorization to do so by all adults who are part of the treatment. When consulting with other psychotherapist, regarding ways to best serve my clients, my client’s identities remain completely anonymous, and confidentiality is fully maintained.
Agreement for Psychotherapy ServicesPsychotherapy Services Agreement • October 11th, 2013
Psychotherapy Services AgreementPsychotherapy Services Agreement • September 26th, 2022
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.
ERIC BERRENSON | MA, LMFT, LIC# 78885Psychotherapy Services Agreement • February 11th, 2014
significant members of the client’s life to become involved in the therapy process, as mutually agreed upon by the therapist and the client. Psychotherapy may involve some risks. Psychotherapy can at times be experiences as emotionally painful. It is difficult to examine oneself, remember unpleasant events, and bring up painful or intense feelings or to change certain familiar patterns. When you make changes, while positive, they might disrupt aspects of your life, such as with your family, relationships or career. Generally, these changes can be worked through and are for the best in the long run. In addition, there is general consensus in outcome research that most people are helped when they are matched with the right therapist, but there is no guarantee that this therapy will lead to the desired result. You may decide to not receive psychotherapy at this office. At your request, you will be provided with the names of other qualified therapists or counseling centers. You may decide
Agreement for Psychotherapy ServicesPsychotherapy Services Agreement • September 30th, 2021
As a licensed clinician, I am governed by various laws and regulations and by the code of ethics of psychology. The ethics code requires that I make you aware of specific laws and office policies and how these procedures may affect you. However, many of these laws and policies may not be relevant to your specific situation.
HIGH-CONFLICT PSYCHOTHERAPY/SERVICES AGREEMENTPsychotherapy Services Agreement • May 24th, 2018
This document is meant to be supplemental to our Agreement for Services and both documents should be signed by families who are signing up for services in the midst of high-conflict and/or at a time where the family is involved in legal processes.
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.
GENERAL INFORMATION & AGREEMENT FOR PSYCHOTHERAPY SERVICESPsychotherapy Services Agreement • November 19th, 2022
a Marriage and Family Therapist Intern [under direct supervision and employment of Dr. Glenn E. McClellan, Ph.D. (license #psy14169), to carry out psychotherapy services and treatment now and during the course of my care as a client.Thank you for taking the time to complete this form. It will take approximately 5 minutes to respond to these prompts and questions. The information obtained here is strictly confidential and will be used to better direct and serve you during our counseling time. If there are some questions you would prefer to bring up in person, feel free to leave them blank or write “will respond later”.) Thank you.
ContractPsychotherapy Services Agreement • September 4th, 2010
Susan StrongM.Ed. in CounselingAZ Licensed Professional Counselor (LPC)AZ Licensed Independent Substance Abuse Counselor (LISAC) Nationally Certified Counselor (NCC)Distance Credentialed Counselor (DCC) Informed Consent
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.
AGREEMENT FOR PYSCHOTHERAPY SERVICES CONDUCTED BY GINGER PASKOWITZ, LCSWPsychotherapy Services Agreement • August 26th, 2020
Consent to treatment: By signing below you hereby give your full consent to receive the evaluation and treatment services of Ginger Paskowitz, LCSW until we determine that services are no longer appropriate or will no longer be provided. You also certify that you have the legal authority to authorize consent to this evaluation and/or treatment.
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
AGREEMENT FOR PSYCHOTHERAPY SERVICES/ INFORMED CONSENTPsychotherapy Services Agreement • May 24th, 2018
This document contains important information about our professional services and business policies. Although these documents are long and sometimes complex, it is very important that you read them carefully. When you sign this document, it will also represent an agreement between us and become a part of your electronic medical record. You may revoke this Agreement in writing at any time. That revocation will be binding on us (and our clinic) unless we have taken action in reliance on it; if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.
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.
