MDCS Privacy Practices and Client Information Agreements
Please read our Notice of Privacy Practices and Client Information Sheet (see link below) and complete this form with your e-signature to indicate you have read and agree with the information shared in this policy.

Notice of Privacy Practices and Client Information Sheet: https://mariadrostecounseling.com/wp-content/uploads/2025/02/Notice-of-Privacy-Practices-Client-Information-Sheet-Feb-2025.pdf
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Email *
Understanding of e-signature *
Please check the box below to indicate you understand that your e-signature is binding, just as your physical signature would be.
Notice of Privacy Practices *
My signature below signifies that I have read and understand these Privacy Practices. Please type your FULL NAME (FIRST, LAST) as your signature:
Client Information Sheet *
I have read the information sheet and have discussed my questions or concerns regarding these policies with an MDCS staff member. I understand and consent to receive services in accordance with these policies. Please type your FULL NAME (FIRST, LAST) as your signature:
TODAY'S DATE -  Do not use date of birth *
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Please note
Note for Minors: If the client is a person under the age of 18 years-old, in the case of divorced or separated parents, both parents are required to sign a separate copy of this document before treatment can begin.

Note for Couples: If you are coming for couples (relational) therapy, both you and the significant other are required to sign a separate copy of this document before treatment can begin.
Name of minor, if completing this on their behalf
Please select the box that applies to you based on the information stated above. *
Please contact your therapist if you have any questions.
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