How did you hear about us? (required)
Postal code (required)
Who should be contacted if there is an emergency (required)
Emergency contact phone (required)
All interactions which take place in the setting of therapy are considered confidential. This includes requests by telephone, all interactions with this counselor, any scheduling or appointment notes, all session content records and any progress notes that I take during your sessions. I will not even verify that you are a client. You may choose to give me permission in writing to release any or specific information about you to any person or agency that you designate.
Limits to this agreement
There may be times when I consult with outside sources about cases. In these cases, no personally identifiable information will be used to discuss this case. However, discussion topics will be used in order to ensure that I am getting and giving the best assistance possible. The persons with whom I discuss cases are legally bound to keep information confidential.
If you need to cancel or reschedule your appointment, you must do so at least 24 hours in advance, or you will be charged full price for the appointment.
I understand I must give 24 hours notice when cancelling/rescheduling an appointment, or I will be charged full price for the appointment.
I have read the above confidentiality policy. I understand the nature and limits of confidentiality.
Date of signing (required)