Enrich Relationship Center of ColoradoTMTherapist-Client Services Agreement • May 29th, 2022
Welcome to Enrich Relationship Center of Colorado, formerly Sauder Psychology, Inc. This document (the Agreement) 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 client rights with regard to the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for the 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 your signature acknowledging that you have been provided with this information. Although these documents are long and sometimes complex, it is very importan
Therapist-Client Services AgreementTherapist-Client Services Agreement • October 25th, 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 new federal law that provides new privacy protections and newpatient rights with regard to the use and disclosureof 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) that I provide for use and disclosure PHI for treatment, payment and healthcare 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 caref
Therapist / Client Services AgreementTherapist / Client Services Agreement • April 11th, 2013
This document contains important information about my professional services and business policies. It also contains your Client Rights and summary information about the Health Insurance Portability and Accountability Act (HIPPA) in the Notice of Privacy Practices. I am required by law to obtain your signature acknowledging that I have provided you with this information at the first session. Please read this document carefully and ask me any questions you may have. When you sign this document, it will represent an agreement between us. This is your informed consent.
THERAPIST-CLIENT SERVICES AGREEMENTTherapist-Client Services Agreement • November 4th, 2020
Nashville Emotional Wellness (NEW) Counseling specializes in providing therapeutic and practical counseling that utilizes systems, tools, strategies and techniques that increase your ability to be your best self. Unlike any other area in life, therapy provides individuals with a relationship that is totally focused on them. Nashville Emotional Wellness (NEW) Counseling builds on this relationship dynamic by meeting you where you are to support you in identifying and standing in your truth. Through focused work on self compassion, acceptance, forgiveness and gratitude, Nashville Emotional Wellness (NEW) Counseling aids in nurturing a sense of emotional safety that allows for the releasing of blockages and the healing of wounds.
Washington StateTherapist-Client Services Agreement • August 23rd, 2021
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 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 by the end of your first session. Although these documents are long and sometimes complex, it is very important that you read them carefu
Therapist-Client Services AgreementTherapist-Client Services Agreement • November 19th, 2020
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 client rights with regard to the use of 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 I have provided you this information at the end of this session. Although these documents are long and sometimes complex, it is very important that you read th
THERAPIST-CLIENT SERVICES AGREEMENTTherapist-Client Services Agreement • August 20th, 2021
This Agreement is intended to provide (herein "Client") with important information regarding the practices, policies and procedures of Kelley Butler, LCSSW #19697 (herein "Therapist"), and to clarify the terms of the professional therapeutic relationship between Therapist, Client, and the Financial Sponsor. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing. This agreement 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 HI
Therapist/Client Services Agreement - AdultTherapist/Client Services Agreement • December 12th, 2019
Welcome to Insight Counseling Center. Starting counseling is a major decision and takes courage and commitment on your part. Clients usually begin counseling because of the desire for certain changes in their life. Counseling is a joint effort between therapist and client and can improve your physical, mental and spiritual well- being as well as your relationships. The role of your therapist is to share ideas, stimulate thought, respect your individual struggles and abilities, and be a creative part of your movement toward your specific goals.
Alyson L. Hatten, M.S., L.P.C., C.R.C., R.P.T. Licensed Professional Counselor, Certified Rehabilitation CounselorTherapist-Client Services Agreement • January 28th, 2014
Therapist/Client Services Agreement – MinorTherapist/Client Services Agreement • December 12th, 2019
Welcome to Insight Counseling Center! We are required by the State of Texas and the U.S. Congress to explain to you a general description of the therapeutic process along with a series of laws and regulations that have been developed to insure your privacy. We are also required to obtain your signed agreement concerning the Health Insurance Portability and Accountability Act (HIPAA), and the Texas State Board of Examiners of Professional Counselors (TSBEPC).
THERAPIST-CLIENT SERVICES AGREEMENTTherapist-Client Services Agreement • October 13th, 2013
Welcome to Latitude Therapeutic Practices, LLC. This Agreement 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 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 you are provided 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 your signature is obtained to acknowledge that this information has been provided to you. Although these documents are long and sometimes complex, it is important that you read them carefully. Feel free to discuss any questions you have about the procedures. When you sign th
Carol G. Fountain Wooten, M.A., L.P.C., N.C.C THERAPIST-CLIENT SERVICES AGREEMENTTherapist-Client Services Agreement • October 10th, 2012
policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law designed to protect your privacy and your 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 the attached Notice of Privacy Practices that explains HIPAA and how it affects you. The law also requires that we obtain your signature acknowledging that you have received this information. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can address any questions you have about the procedures before your next session. When you
Therapist – Client Services AgreementTherapist – Client Services Agreement • March 7th, 2024
This document is a formal agreement between you as a client and AGAPE. It is important for you to understand this agreement so please read this document carefully and ask your counselor any questions you may have. After reading this document, please sign the Acknowledgement of Agreement for Services and HIPAA Notice (included in the New Client Forms). By signing, you indicate you have read, understand, and accept the terms of this agreement. Once you sign the Acknowledgement form you become an AGAPE client. Your signature also documents that AGAPE has informed you of our privacy practices and your rights under the Health Insurance Portability and Accountability Act (HIPAA).
Serenity Solutions, LLCTherapist-Client Services Agreement • April 28th, 2016
During your first few sessions, your therapist will be gathering information about your background and the problems and symptoms you are experiencing in order to evaluate your needs. By the end of this assessment period we may be able to give you some impression of what your work will include and what goals you will be attempting to accomplish during your therapy. Therapy is shaped by your personality, the training and characteristics of your therapist, and the particular problems you are experiencing. Unlike most visits to a doctor or medical specialist, therapy involves an active partnership between you and your therapist.
THERAPIST-CLIENT SERVICES AGREEMENTTherapist-Client Services Agreement • June 27th, 2024
This document also contains information related to 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 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 will be provided to you in the form of a handout and will explain 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 during our initial meeting/ session. 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 the procedures at any time. When yo
SUNRISE COUNSELINGTherapist-Client Services Agreement • March 28th, 2022
Therapist–Client Services AgreementTherapist–client Services Agreement • April 24th, 2016
Work in Progress, LLC is committed to providing direction, guidance, and support in a safe environment for those who desire emotional, relational, and spiritual healing. Please discuss any questions or concerns with your therapist after reading through this Agreement.
THERAPIST-CLIENT SERVICES AGREEMENTTherapist-Client Services Agreement • October 28th, 2020
Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. It also makes reference to 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 explains HIPAA and its application to your personal health information in greater detail, and, as this form explains, you need to acknowledge receiving it. Although these policies 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,
Enrich Relationship Center of ColoradoTMTherapist-Client Services Agreement • September 12th, 2021
Welcome to Enrich Relationship Center of Colorado, formerly Sauder Psychology, Inc. This document (the Agreement) 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 client rights with regard to the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for the 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 your signature acknowledging that you have been provided with this information. Although these documents are long and sometimes complex, it is very important
Work in Progress, LLCTherapist–client Services Agreement • April 24th, 2016
With my signature below, I acknowledge that I have read the “Therapist–Client Services Agreement” available on Work in Progress’s website at www.workinprogresscounseling.com, understand its content, and agree to abide by the terms therein:
AGAPE Therapist – Client Services AgreementTherapist – Client Services Agreement • April 24th, 2018
This document serves as the basis for a formal agreement between you as a client/patient and AGAPE. It is important for you to understand this agreement so please read this document in its entirety and ask your counselor/therapist about anything that is unclear to you. After reading this document, please sign the Acknowledgement of Agreement for Services and HIPAA Notice (included in the New Client Forms) indicating that you have read, understand, and accept the terms of this agreement. Once you sign the Acknowledgement form you become an AGAPE client. Your signature also documents that AGAPE has informed you of our privacy practices and your rights under the Health Insurance Portability and Accountability Act (HIPAA).
Michael “Raúl” Brown, MS, Ph.D., LCMHCA Therapist-Client Services AgreementTherapist-Client Services Agreement • September 23rd, 2022
This document contains important information about your therapist, your privacy, and our work together. It is important that you read this information carefully. Please let me know if you have any questions once you have read through it. Before treatment can proceed, you will be asked to sign this agreement.
Therapist-Client Services AgreementTherapist-Client Services Agreement • April 5th, 2021
Welcome to Pitts & Associates. 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 patient rights with regards to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.
PAULA J. DETJEN, PLLC MA, LMFT, LPC Phone (507) 581-0430; Fax (507) 663-8849 Northfield Office Paula@DetjenCounseling.com Burnsville Office 105 E. Fourth St., Suite 301 www.DetjenCounseling.com 14041 Burnhaven Drive, Suite 145 Northfield, MN 55057...Therapist / Client Services Agreement • July 4th, 2019
This document contains important information about my professional services and business policies. It also contains your Client Rights and summary information about the Health Insurance Portability and Accountability Act (HIPPA) in the Notice of Privacy Practices. I am required by law to obtain your signature acknowledging that I have provided you with this information. When you sign this document, it will represent an agreement between us. This is your informed consent.
Kevin Karl, LCSW, PLLCTherapist - Client Services Agreement • September 15th, 2009
Welcome! I am a licensed clinical social worker. I focus on mental health difficulties, solving problems in relationships, and resolving difficulties arising from developmental changes and stressful life situations. As a social worker, I approach issues from many perspectives. I am trained in assessment and treatment and am prepared to use a variety of therapeutic methods and processes. I observe a strict ethical code and welcome inquiries about my training, experience, orientation, treatment goals, and fees for service.
ContractTherapist-Client Services Agreement • January 11th, 2015
THERAPIST-CLIENT SERVICES AGREEMENT CHARLES A. SCHAEFER, PH.D., INC.Therapist-Client Services Agreement • January 1st, 2013
policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law designed to protect your privacy and your 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 the attached Notice of Privacy Practices that explains HIPAA and how it affects you. The law also requires that we obtain your signature acknowledging that you have received this information. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can address any questions you have about the procedures before your next session. When you
THERAPIST-CLIENT SERVICES AGREEMENT CATHERINE M. LESLIE, PH.D., PLLCTherapist-Client Services Agreement • September 11th, 2010
THERAPIST-CLIENT SERVICES AGREEMENTTherapist-Client Services Agreement • June 16th, 2021
This document contains information about our services and business policies and a summary of the Health Insurance Portability and Accountability Act (HIPAA). This federal law provides privacy protections and patient rights regarding 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 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 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. When you sign this document, it will represent an agreement between us. You may revoke the Agreement in writing at any time. That revocation will be binding on us unle
Melissa Ann Russiano, LCSW, LISWTherapist-Client Services Agreement • November 19th, 2020
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 client rights with regard to the use of 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 I have provided you this information at the end of this session. Although these documents are long and sometimes complex, it is very important that you read th
Erica N. Green, LCSWTherapist-Client Services Agreement • November 23rd, 2021
Therapist-Client Services AgreementTherapist-Client Services Agreement • August 17th, 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 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 purposes of treatment, payment and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) that I provide for use and disclosure PHI for treatment, payment and healthcare 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 car
THERAPIST-CLIENT SERVICES AGREEMENTTherapist-Client Services Agreement • September 22nd, 2021
Welcome to my practice. The Health Insurance Portability and Accountability Act (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. Although these policies 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.
THERAPIST-CLIENT SERVICES AGREEMENTTherapist-Client Services Agreement • August 27th, 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 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.
THERAPIST-CLIENT SERVICES AGREEMENTTherapist-Client Services Agreement • February 11th, 2020
Welcome. This document contains important information about our practice and its business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law designed to protect your privacy and your 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 the attached Notice of Privacy Practices that explains HIPAA and how it affects you. The law also requires that we obtain your signature acknowledging that you have received this information. Although these documents are long and sometimes complex, it is very important that you read them carefully. I can address any questions you have about the procedures before your next session. When you sign this document, it will also represent an agreement between you and Diane T. Jacob, MA, MA, LPCA, your therapist. You may revoke this Agree
