re: Consent for Treatment & Cancellation Policy

Please correct the errors described below.

Please read the following in entirety and digitally sign and date your agreement at the bottom. Limits of Services and Assumption of Risks: Therapy sessions carry both benefits and risks. Therapy sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, these improvements and any “cures” cannot be guaranteed for any condition due to the many variables that affect these therapy sessions. Experiencing uncomfortable feelings, discussing unpleasant situations and/or aspects of your life are considered risks of therapy sessions. Limits of Confidentiality: What you discuss during your therapy session is kept confidential. No contents of the therapy sessions, whether verbal or written, may be shared with another party without your written consent or the written consent of your legal guardian. The following is a list of exceptions: Duty to Warn and Protect: If you disclose a plan or threat to harm yourself, the therapist must attempt to notify your family and notify legal authorities. In addition, if you disclose a plan to threat or harm another person, the therapist is required to warn the possible victim and notify legal authorities. Abuse of Children and Vulnerable Adults If you disclose, or it is suspected, that there is abuse or harmful neglect of children or vulnerable adults (i.e. the elderly, disabled/incompetent), the therapist must report this information to the appropriate state agency and/or legal authorities. Prenatal Exposure to Controlled Substances Therapists must report any admitted prenatal exposure to controlled substances that could be harmful to the mother or the child. Minors/Guardianship Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records. Insurance Providers Insurance companies and other third-party payers are given information that they request regarding services to the clients. The type of information that may be requested includes: types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, summaries, etc. By signing below, I agree to the above assumption of risk and limits of confidentiality and understand their meanings and ramifications.

Please include your full name here. You will be asked to physically sign and date this form at first session.

re: Cancellation Policy

Cancellation Policy If you are unable to attend an appointment, we request that you provide at least 24 hours advanced notice to our office. Since we are unable to use this time for another client, please note that you will be billed for the entire cost of your scheduled appointment if it is not timely cancelled, unless such cancellation is due to illness or an emergency. For cancellations made with less than 24 hour notice (unless due to illness or an emergency) or a scheduled appointment that is completely missed, you will be mailed a bill directly for the full session fee. We appreciate your help in keeping the office schedule running timely and efficiently.

Please include your full name here. You will be asked to physically sign and date this form at first session.

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