THERAPIST-CLIENT SERVICE AGREEMENTTherapist-Client Service Agreement • September 22nd, 2021
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 federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
INFORMED CONSENT-Therapist/Client Service AgreementTherapist/Client Service Agreement • February 11th, 2022
Welcome to Enso Counseling, LLC. This document contains important information R. Sean Rollinson, LPC’s 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 about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
THERAPIST-CLIENT SERVICE AGREEMENTTherapist-Client Service Agreement • June 2nd, 2020
Welcome to The TNC Psychotherapy Group, PLLC. 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 privacy protections and Client rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. You and your therapist can discuss any questions you have when you sign them or at any time in the future.
THERAPIST - CLIENT SERVICE AGREEMENTTherapist - Client Service Agreement • July 1st, 2024
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 federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. When you sign this document, it represents an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
JENNIFER BLOOM, LCSWTherapist-Client Service Agreement • May 21st, 2019
THERAPIST-CLIENT SERVICE AGREEMENTTherapist-Client Service Agreement • November 4th, 2017
Welcome to Mosaic Counseling Group, LLC. 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 privacy protections and client rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between you and your therapist. You and your therapist can discuss any questions you have when you sign them or at any time in the future.
Reflections Psychotherapy, P.C. Therapist-Client Service AgreementTherapist-Client Service Agreement • January 4th, 2022
This document contains important information about our professional services and business policies. You will also have an opportunity to review information about the Health Insurance Portability and Accountability Act (HIPPA), 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 options. The law requires that we obtain your signature acknowledging that I have provided you with this information at the first session. When you sign this document, it will represent an agreement between you and Reflections Psychotherapy, P.C. Please carefully review the following information and feel free to ask any questions you may have.
INFORMED CONSENTTherapist-Client Service Agreement • June 4th, 2022
Welcome! Thank you for making the decision to begin therapy with me. This document contains important ethical and legal information about my professional services and policies. It also contains information about your rights as a client, including privacy, treatment, payment, and healthcare operations. After reading and signing this document, it will represent an agreement of services between us. If you have any questions prior to signing, please ask!
Therapist-Client Service AgreementTherapist-Client Service Agreement • October 15th, 2019
THERAPIST-CLIENT SERVICE AGREEMENT-INFORMED CONSENT FOR PARENTS OF MINOR CHILDRENTherapist-Client Service Agreement • January 29th, 2020
Prior to beginning treatment, it is important for you to understand our therapists’ 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.
KW Counseling Services, LLCTherapist - Client Service Agreement • March 25th, 2022
This document contains important information about the professional services and business policies for KW Counseling Services, LLC. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), which is a federal law that provides privacy protections and client rights with regard to the use and disclosure of your Protected Health Information (PHI) that is used for the purpose of treatment, payment, and health care operations.
LINDA M. CALLAHAN MSW, LCSW 6224 NW 43RD ST. 4 ATherapist-Client Service Agreement • March 8th, 2022
Informed Consent for Therapy Services Channing Gould-Sanderson, LMHC THERAPIST- CLIENT SERVICE AGREEMENTTherapist-Client Service Agreement • January 1st, 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 federal law that provides privacy protections and your rights as a client about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations that are important that you understand. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign this document, or at any time in the future.
INFORMED CONSENT-Therapist/Client Service AgreementTherapist/Client Service Agreement • February 5th, 2020
Welcome to Enso Counseling, LLC. This document contains important information R. Sean Rollinson, LPC’s 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 about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
Wholeistic You, PLLC THERAPIST-CLIENT SERVICE AGREEMENTTherapist-Client Service Agreement • August 5th, 2019
This document contains important information about our professional services and business policies. You will have the opportunity to review information about the Health Insurance Portability and Accountability Act (HIPPA), 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 options. The law requires that we obtain your signature acknowledging that I have provided you with this information at the first session. When you sign this document, it will represent an agreement between you and Wholistic You. Please carefully review the following information and feel free to ask any questions you may have.
THERAPIST-CLIENT SERVICE AGREEMENTTherapist-Client Service Agreement • April 9th, 2022
Welcome to Resolve Counseling Center. This document contains important information about 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 about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
THERAPIST-CLIENT SERVICE AGREEMENTTherapist-Client Service Agreement • September 2nd, 2020
Welcome to New Hope Behavioral Health, LLC. 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 about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations.
THERAPIST-CLIENT SERVICE AGREEMENTTherapist-Client Service Agreement • September 1st, 2020
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 federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
KW Counseling Services, LLC 2219 229th PlaceTherapist – Client Service Agreement • December 22nd, 2021
This document contains important information about the professional services and business policies for KW Counseling Services, LLC. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), which is a federal law that provides privacy protections and client rights with regard to the use and disclosure of your Protected Health Information (PHI) that is used for the purpose of treatment, payment, and health care operations.
Therapist / Client Service AgreementTherapist / Client Service Agreement • May 31st, 2021
This document contains important information about FAMILY CIRCLE COUNSELING professional services and business policies. It also contains Client Rights and summary information about the Health Insurance Portability and Accountability Act (HIPPA) in the Notice of Privacy Practices.
Eva Hudlicka, LICSW, MSW, PhD – PsychotherapyTherapist-Client Service Agreement • August 31st, 2022
THERAPIST - CLIENT SERVICE AGREEMENTTherapist - Client Service Agreement • July 18th, 2017
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 federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
Therapist-Client Service AgreementTherapist-Client Service Agreement • January 2nd, 2022
Reflections Psychotherapy Therapist-Client Service AgreementTherapist-Client Service Agreement • August 9th, 2020
This document contains important information about our professional services and business policies. You will also have an opportunity to review information about the Health Insurance Portability and Accountability Act (HIPPA), 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 options. The law requires that we obtain your signature acknowledging that I have provided you with this information at the first session. When you sign this document, it will represent an agreement between you and Reflections Psychotherapy, Inc. Please carefully review the following information and feel free to ask any questions you may have.
THERAPIST-CLIENT SERVICE AGREEMENT-INFORMED CONSENTTherapist-Client Service Agreement • January 29th, 2020
The following is a description of your rights and responsibilities. Please read carefully before signing your consent to meet with a therapist.
