Consent for the Provision of Services to a Minor
Please fill out this form before your first visit. If you are over 18 please fill out the Adult Intake Form by clicking here: https://docs.google.com/forms/d/e/1FAIpQLSeizNvZbkJgzsWBV-nObPmblyUBTrQ5hMiyhPmNBgc6eBCAEQ/viewform
I/We, (your name(s)) parent(s)/guardian(s) *
Please list your children by name and birthdate: *
Prior to beginning treatment, it is important for you to understand Impact Counseling and Coaching, LLC approach to child assessment and therapy, and to 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 PSYCHOTHERAPIST/RESIDENT IN COUNSELING-PATIENT SERVICES AGREEMENT (HIPAA) Notice of Privacy Practices. Under HIPAA and the APA Ethics Code, we are legally and ethically responsible to provide you with informed consent. Consent although having only one parent’s consent for assessment and/or treatment may be legal, it is the preferred practice of this office to obtain consent from both parents, regardless of the custodial arrangement, before an assessment or treatment begins with a minor. In any custodial arrangement, both parents have the right to contact and meet with the Therapist/Resident in Counseling regarding their child’s assessment or treatment progress (unless otherwise indicated by the courts). In turn, the Therapist/Resident in Counseling has the right to contact both parents to share critical information and to seek supportive information. In some situations, disagreement between parents and/or disagreement between parents and the Therapist/Resident in Counseling may arise regarding the best interests of the child. If such disagreements occur, the Therapist/Resident in Counseling will strive to listen carefully to understand the parents’ perspectives, and to fully explain the Therapist/Resident in Counseling’s perspective. These disagreements may be resolved, or parents and Therapist/Resident in Counseling may agree to disagree, so long as this enables the child’s therapeutic progress. Ultimately, parents will decide whether therapy will continue. If either parent decides that therapy should end, the Therapist/Resident in Counseling will honor that decision; however, parents are asked to allow the Therapist/Resident in Counseling the option of having a few closing sessions to appropriately end the treatment relationship. Minor Confidentiality for Therapy In the case of child therapy, it is most effective when a trusting relationship exists between the psychologist and the patient. Privacy is especially important in securing and maintaining that trust. One goal of treatment is to promote a stronger and better relationship between children and their parents. It is often necessary, however, for children to develop a “zone of privacy” whereby they feel free to discuss personal matters with greater freedom. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy. By signing this agreement, you will be waiving your right of access to your child’s treatment records. It is the policy of ICC Therapist/Resident in Counseling to provide you with general information about your child’s (i.e. 12 years and younger) treatment status and to encourage teenage children to share directly with their parents. Your child’s Therapist/Resident in Counseling will raise issues that may be affecting your child either inside or outside the home. If it is necessary to refer your child to another mental health professional with more specialized skills, the Therapist/Resident in Counseling will share that information with you. The Therapist/Resident in Counseling will not share with you what your child has disclosed to him/her without your child’s assent. The Therapist/Resident in Counseling will encourage your child to regularly provide you with a summary that will describe what issues were discussed, what progress was made, and what areas are likely to require intervention in the future. In addition, the Therapist/Resident in Counseling will periodically request that you provide supportive information in order for him/her to best help your child and the family. Please type initial(s) here: *
If your child is an adolescent, it is possible that he/she will reveal sensitive information regarding sexual contact, alcohol and drug use, or other potentially problematic behaviors. Sometimes these behaviors are within the range of normal adolescent experimentation, but at other times they may require parental intervention. We must carefully and directly discuss your feelings and opinions regarding acceptable behavior. If an ICC Therapist/Resident in Counseling ever believes that your child is at serious risk of harming him/herself or another, they will inform you. Examples of serious risk would include a plan to harm self or suicidal ideation which is intensifying. If you are participating in therapy with your child, you should expect the clinician to request that you examine your own attitudes and behaviors to determine if you can make positive changes that will be of benefit to your child. Agreement Not to Involve Therapist/Resident in Counseling in Custody Disputes When parents bring their children for psychological therapy, it is important that both parents consent to treatment knowing that the role of the clinician is as the child (or family) Therapist/Resident in Counseling, and not as an “expert witness.” Although the Therapist/Resident in Counseling’s responsibility to your child may require his/her involvement in conflicts between the parents, you agree that the Therapist/Resident in Counseling’s involvement will be strictly limited to that which will benefit your child. This means that you agree not to involve the Therapist/Resident in Counseling in any custody or visitation disputes, as this would not be in the best interest of your child’s relationship with the Therapist/Resident in Counseling, and would be counterproductive to the therapeutic process. In particular, you agree not to involve the Therapist/Resident in Counseling in court proceedings regarding any treatment of your child now or in the future, nor to ask the Therapist/Resident in Counseling to share your child’s records regarding any such proceedings. You also agree to instruct your attorneys not to subpoena the Therapist/Resident in Counseling, or to refer in any court filing to anything the Therapist/Resident in Counseling has said or done. Note that such agreement may not prevent a judge from requiring the Therapist/Resident in Counseling’s testimony, even though the Therapist/Resident in Counseling will work to prevent such an event. If the Therapist/Resident in Counseling is required to testify, he/she is ethically bound not to give an opinion about either parent’s custody or visitation suitability. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, the Therapist/Resident in Counseling will provide information as needed (if both parents sign appropriate releases), but the Therapist/Resident in Counseling will not make any recommendation about the final decision. Furthermore, if the Therapist/Resident in Counseling is required to appear as a witness, the party responsible for the Therapist/Resident in Counseling’s participation agrees to reimburse ICC at the rate of $50 per hour, in addition to their normal fee, for time spent traveling, preparing reports, testifying, being in attendance, and any other case related costs. In signing this agreement, I acknowledge that there is a difference between the roles of treating Therapist/Resident in Counseling and expert witness, and I agree not to subpoena the Therapist/Resident in Counseling, or the Therapist/Resident in Counseling’s records, for use in litigation. I understand that the boundary between treating Therapist/Resident in Counseling and expert witness is necessary to maintain the integrity of the therapeutic relationships established in therapy. By typing your name(s) below, as well as the date, you are electronically singing this legal document. *
Today's Date: *
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Referred by: *
Referring Person's Address: *
Referring Person's Phone Number: *
First Name: *
Middle Initial: *
Last Name: *
SS# *
Date of Birth: *
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Marital Status *
Address: *
City: *
State: *
Zip Code: *
Cellular Phone:
Home Phone:
Work Phone:
Email:
Employer: *
Occupation: *
Emergency Contact Name: *
Relation to You: *
Emergency Contact Phone #: *
Partner/Spouse Name: *
Partner/Spouse Occupation: *
Partner/Spouse DOB: *
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Partner/Spouse Employer: *
Partner/Spouse Phone #: *
Children Name(s) and DOBs: *
Provide a brief statement about the problem(s) for which you are seeking help. *
Why do you think the problem(s) exists? *
Have you sought help before with this problem(s)? Where, when, and how? *
What results did you have? (if applicable)
Are you currently working with any other mental health provider(s)? *
If yes, please give names, addresses, and phone numbers
Who is your primary care physician? *
Provide their address and phone: *
Are you taking any prescribed medications? *
If yes, please list types, dosages, and the prescribing physician
Have you used alcohol in the past 30 days *
If yes, please state the frequency of use and amount
Have you used illegal or non-prescribed drugs in the past 30 days *
If yes, please state the frequency of use and amount
Have you used tobacco in the past 30 days? *
If yes, please state the frequency of use and amount
Have you used caffeine in the past 30 days? *
If yes, please state the frequency of use and amount
Describe any physical problems you have been experiencing during the past month. *
Describe your expectations of how therapy will help you. *
What methods do you use for relaxation? *
What spiritual practices are in your life? *
Describe, if applicable, any history of physical or sexual abuse/assault as a child or adult. *
What are some beliefs you hold about yourself? *
How do other people in your life relate to you? How do you think other people describe you? *
Within the last 30 days, please describe the following thoughts and emotions. *
Required
Depressed Mood *
Hopelessness *
Suicidal Thinking *
Disturbed Sleep (increase or decrease) *
Appetite Changes (increase or decrease) *
Slowed Activity *
Significant Weight Loss *
Poor Concentration *
Poorly Groomed *
Agitation *
Elated Mood *
Mood Swings *
Emotions being hard to control *
Obsessive Thoughts *
Tense/Anxious *
Fearful (phobic) *
Physical Problems *
Hard to Keep Train of Thought *
Inappropriate Speech or Sounds *
Hallucinations *
Impaired Intellectual Functions *
Impaired Judgement *
Long-term Memory Deficit *
Short-term Memory Deficit *
Paranoia *
Delusions *
Hostile Feelings Towards Self or Others *
Violence Towards Self or Others *
Illegal Behavior *
Conflict with Authority *
Disruptive Conduct *
Social Isolation *
Dissociative Episodes (amnesia, losing consciousness) *
In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (grandfather, grandmother, uncle, etc.). *
Required
Abuse As Victim *
Required
Abuse as Perpetrator *
Required
Alcohol/Substance Abuse *
Required
Anxiety *
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ADD/ADHD *
Required
Panic Attacks *
Required
Depression *
Required
Divorce *
Required
Bi-Polar or Manic Depression *
Required
Domestic Violence *
Required
Eating Disorder *
Required
NOTICE OF PRIVACY PRACTICES This document (the Agreement) contains important information about the professional services and business policies of Impact Counseling & Coaching, LLC (ICC). It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA). HIPAA is 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 ICC provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of 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 ICC obtain your signature acknowledging that ICC has provided you with this information prior to the end of your session. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss questions you have about the procedures at any time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the Psychotherapist/Resident in Counseling and patient, and the particular problems you are experiencing. There are many different methods Therapist/Resident in Counseling at ICC may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Psychotherapy has also shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. In addition, therapy may be experiential at times. Therefore, you may be requested to participate physically. Please notify your Therapist/Resident in Counseling of any physical limitations and know that you have the right to refuse. Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, your Therapist/Resident in Counseling will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with your Therapist/Resident in Counseling. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the Therapist/Resident in Counseling you select. If you have questions about our procedures, you should discuss them whenever they arise. If your doubts persist, we encourage you to set up a meeting with another mental health professional for a second opinion. It is important each client have awareness that some ICC groups may include men and women, victims, and victimizers presenting with a variety of issues. Our groups vary from process oriented to experiential. During the experiential groups, you may be asked to physically participate. Please notify the group leader of any physical limitations and we understand it is always your right to refuse to participate. Please note that our SOS group specifically focuses on the needs of sex offenders but we also offer groups around marriage, depressions, anxiety and ADHD. MEETINGS/SCHEDULING We normally conduct an evaluation that will last from 2 to 4 sessions. During this time, you and your Therapist/Resident in Counseling can decide if he/she is the best person to provide the services that you need in order to meet your treatment goals. We define a “therapy hour” as a 45 minute session. Once an appointment is scheduled, you will be responsible to pay for that session unless you provide 24 hours advance notice of cancellation (unless your Therapist/Resident in Counseling and you both agree that you were unable to attend due to circumstances beyond your control). The 24 hours translates to one business day, not including weekends or holidays. If you need to call to schedule an appointment, please call 757-354-3025 any time. There may be times when we need to contact you by phone or text. Please inform us if you do not want us to leave a message at any of the phone numbers you provided. CANCELLATION POLICY A one– (1) hour session requires 24 hour notice not including weekends or holidays to cancel without penalty. A two- (2) hour session requires 48 hours’ notice not including weekends or holidays to cancel without penalty. If you need to cancel or change an appointment, please call (757)216-9126 or call/ text your individual Therapist/Resident in Counseling contact number any time. Please remember that you will be charged when you do not show for a scheduled appointment per your Therapist/Resident in Counseling’s discretion. PROFESSIONAL FEES The fee associated with therapy varies from ICC Therapist/Resident in Counseling to ICC Therapist/Resident in Counseling. The fee is based upon a 50 minute session and ranges from $50 to $350. The fee remains the same for couples and family therapy. Group therapy charges range from $25 to $85 per group therapy session. In addition to weekly appointments, we charge for other professional services you may need, though we will break down the hourly cost if we work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of us. Each letter will incur a 15 minute charge at the Therapist/Resident in Counseling’s rate. If the letter involves more than 15 minutes, you will be charged in 15 minute increments. If you become involved in legal proceedings that require our participation, you will be expected to pay for all of our professional time, including preparation and transportation costs, even if one of our Therapist/Resident in Counseling is called to testify by another party. For any court or legal related work there will be an additional charge of $50 for each hour. In addition, any time spent (i.e., phone calls, emails, report and letter writing, etc.) will also be charged. CONTACTING ICC Therapist/Resident in Counseling will make every effort to return your call within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform us of some times when you will be available. If you are unable to reach us and feel that you can’t wait for us to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If your Therapist/Resident in Counseling will be unavailable for an extended time, she/he can provide you with the name of a colleague to contact at ICC, if necessary. Due to privacy issues we do not communicate with clients by email. Do not use email for emergency contact. In addition, ICC Therapist/Resident in Counseling do not process therapeutic information over the phone. It is our policy for clients to utilize their therapy time face to face rather than attempting to process over the phone or email. SOCIAL MEDIA We recognize clients may find an ICC Therapist/Resident in Counseling has an online presence through Facebook, LinkedIn, or some other web service or application. It is the policy of ICC Therapist/Resident in Counseling to avoid online relationships with our clients. Our regulatory boards and ethical codes classify them as dual relationships. Please feel free to discuss this boundary with your Therapist/Resident in Counseling. VIDEO CONFERENCING COUNSELING SESSIONS If you choose to do your counseling sessions via video conferencing, you do so knowing that you are using a vendor who may or may not have declared that they won't provide providers with a "Business Associate Agreement," as mandated by HIPAA. Please see attached agreement form for more information. MINORS AND PARENTS For patients under 18 years of age, their parents must review and sign the ICC CONSENT FOR THE PROVISION OF SERVICES TO A MINOR form. Consent from both parents, regardless of the custodial arrangement, is the preferred practice of this office. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from parents to allow their child’s records to remain private. ICC Therapist/Resident in Counseling will provide you with general information about your child’s (i.e. 12 years and younger) treatment status and will encourage teenage children to share directly with their parents. The Therapist/Resident in Counseling will not share with you what your child has disclosed to him/her without your child’s assent. If an ICC Therapist/Resident in Counseling believes that your child is at serious risk of harming him/herself or another, they will inform you. Examples of serious risk would include a plan to harm self or suicidal ideation which is intensifying. Parents agree not to involve the Therapist/Resident in Counseling in any custody or visitation disputes, as this would not be in the best interest of your child’s relationship with the Therapist/Resident in Counseling, and would be counterproductive to the therapeutic process. BILLING AND PAYMENTS You will be expected to pay for each session prior to the time it is held or immediately following the end of each session by cash, credit card or PayPal. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. (If such legal action is necessary, the costs will be included in the claim.) LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a patient and a Psychotherapist/Resident in Counseling. In most situations, we can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, we make every effort to avoid revealing the identity of our patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, your Therapist/Resident in Counseling will not tell you about these consultations unless he/she feels that it is important to your work together. We will note all consultations in your Clinical Record (which is called “PHI” in our Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). You should be aware that we practice as a group with other mental health professionals and that we employ administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. It is common practice for ICC Therapist/Resident in Counseling to share cases. Therefore, it is likely your progress notes will be viewed by other Therapist/Resident in Counseling. We also may have contracts with an attorney, accounting firm, computer Technology Company, and collection agency. As required by HIPAA, we have a formal business associate contract with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, we can provide you with the names of these organizations and/or a blank copy of this contract. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If a patient threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. I will also obtain an authorization from you before using or disclosing: PHI in a way that is not described in this Notice. PSYCHOTHERAPY NOTES There are some situations where we are permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning the professional services we provided you, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your or your legal representative’s written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. If a government agency is requesting the information for health oversight activities, we may be required to provide it for them. If a patient files a complaint or lawsuit against us, we may disclose relevant information regarding that patient in order to defend ourselves. If a patient files a worker’s compensation claim, and we are providing services related to that claim, we must, upon appropriate request, provide appropriate reports to the Workers Compensation Commission or the insurer. There are some situations in which we are legally obligated to take actions, which we believe are necessary in an attempt to protect others from harm and we may have to reveal some information about a patient’s treatment. These situations are unusual in our practice. If we have reason to believe that a child under 18 who we have examined is or has been the victim of injury, sexual abuse, neglect or deprivation of necessary medical treatment, the law requires that we file a report with the appropriate government agency, usually the Office of Child Protective Services and the local police department. Once such a report is filed, we may be required to provide additional information. If we have reason to believe that any adult patient who is either vulnerable and/or incapacitated and who has been the victim of abuse, neglect or financial exploitation, the law requires that we file a report with the appropriate state official, usually a protective services worker. Once such a report is filed, we may be required to provide additional information. If a patient communicates an explicit threat of imminent serious physical harm to a clearly identified or identifiable victim, and we believe that the patient has the intent and ability to carry out such threat, we must take protective actions that may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the Privacy Rule and the state’s confidentiality law. This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not qualified attorneys. In situations where specific advice is required, formal legal advice may be needed. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that we amend your record (must be made in writing); requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures. You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services. You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised. Your Psychotherapist/Resident in Counseling will be happy to discuss any of these rights with you. Typing your full name below constitutes your online signature of this legal document. *
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Fill out the final question only if you are partaking in video conferencing. *
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I, (YOUR NAME) am choosing to facilitate my counseling sessions via the internet using video conferencing with an ICC Therapist/Resident in Counseling. By choosing this option, I understand that: • Video conferencing is an online communication tool allowing for face-to-face video, voice, or text-based chat dialogue. Video conferencing-to-Video conferencing calling is encrypted using the same standards utilized by the US government to protect sensitive information. • Video conferencing software must be downloaded onto a computer and an account setup. • Search for and add therapist's username to your contacts as shared with you by your Therapist/Resident in Counseling. • Appointments will be made via email or set up at the end of your private session. Please be online at least five minutes prior to session, alone, in a quiet room, door closed. Therapist will call you at scheduled appointment time. I also understand the following limitations of Video conferencing video therapy sessions: • Video conferencing encryption technology utilizes the "AES encryption protocol", it meets the Federal Information Processing Standards (FIPS) for electronic transmission under HIPAA. However please note that: One major issue with Video conferencing is the fact that they have been unwilling to declare that they are HIPAA compliant or sign a BAA (Business Associate Agreement) which is a necessary requirement for HIPAA compliance. This means that Video conferencing does not disclose security breaches or findings from security audits. Therefore, if you use Video conferencing, you do so knowing that you are using a vendor who may not have declared that they won't provide providers with a "Business Associate Agreement," as mandated by HIPAA. • In a crisis or emergency situation that needs immediate attention, whereby I am considering seriously harming myself or someone else, I will call the National Suicide Hotline at 800-784-2433, dial 911 or go to a mental health hospital/ER. • Confidentiality should be treated like an in office session: no outside distractions, turn off cell phones, close other programs on computer and don’t be late. • Technical problems could occur. If the call is disrupted, the therapist will call back within ten minutes. If reconnection cannot occur, the session will be rescheduled through email. • The online therapy sessions are not to take place of regular in office sessions, but are being utilized when in office sessions cannot be scheduled for a length of time and the therapist and client deem it necessary for contact. Typing your name below constitutes your electronic signature of this legal document.
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