Common use of Consent to Treatment Clause in Contracts

Consent to Treatment. I/We hereby authorize and request that Xxxx Xxxx, LMFT carry out mental health examinations, treatments, and/or diagnostic procedures which now or during the course of my care are advisable. I/We understand that the purpose of these procedures will be explained to me and be subject to my agreement. I/We understand that I am consenting and agreeing only to those services that the above named provider is qualified to provide within the scope of the provider's license, certification, and training. If the patient is under 18 or unable to consent to treatment, I attest that I am authorized to initiate consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual. Process of Evaluation and Treatment: You will be evaluated based on the information that you (and/or your parent or guardian) provide. You and your therapist will come up with a Treatment Plan based on this information along with the therapist’s assessment of the symptoms and problems presented. Therapy is a unique experience for each person and the results depend greatly on the collaboration between the therapist and the client or clients. You may be asked for your feedback and views on your therapy, its progress, and other aspects of your treatment. Your honesty and openness with your clinician will help determine which approach(es) are the best course of treatment for you. Try to think of the relationship as a partnership focused on you! There is no guarantee that psychotherapy will yield positive or intended results. Please be aware that therapy can sometimes be difficult or even painful but the goal is always to help you to feel better and to live a healthier life. The benefits of therapy may include a reduction in distress, improved interpersonal relationships, and solutions to specific problems. During the course of treatment you may experience uncomfortable feelings while discussing unpleasant aspects of your life. These feelings may include sadness, guilt, anger, frustration, loneliness, helplessness, and insomnia. During the course of treatment, your therapist may use various psychological approaches/treatments based on his/her assessment of what will best treat your problems. These therapeutic approaches may include cognitive behavioral, behavioral, family systems, psychodynamic, developmental, psycho- educational, or religious-based. Termination: Therapy usually ends when the therapist and the client agree that the treatment goals have been reached. Sometimes life changes bring out further issues to address. At any time during treatment it may be determined that your specific needs require you to be referred to another healthcare provider. Referrals will be provided if it is medically necessary, or if you or your therapist believe that your treatment is not effective in helping you reach your therapeutic goals. You have the right to terminate therapy at any time. Your therapist will provide you with the numbers of treatment providers that you may prefer at your request. If you choose to and authorize in writing, your therapist will assist with you in communicating with the treatment provider of your choice verbally or in writing. Minors: Please note that the records of a minor or person under the care of a legal guardian are accessible to the parent or guardian. The therapist can withhold certain information if it is in the best interest of the child or xxxx for therapeutic or safety reasons. The therapist does not have to disclose information about sexually transmitted diseases, termination of pregnancy, substance abuse, or any other information that your therapist feels would adversely affect the health or welfare of the child, unless the life of the child or xxxx is in danger. By signing this agreement, parents/guardians agree to give up their rights to access the treatment records of minors in order to maintain the therapeutic relationship between the clinician and minor. Parents will be provided only with general information about treatment, unless your clinician perceives that there is a high risk that you will seriously harm yourself or someone else. In this case, your clinician will notify parents of the concern. Parents are encouraged to be active in their minor’s treatment by providing feedback to the clinician during treatment. Parents are also encouraged to communicate any questions or concerns to their minor’s clinician at any time. In treatment involving minor clients, if the client’s parents are not married, both parents must sign the contract or provide a copy of your divorce papers to be reviewed. Dual Relationships: Psychotherapy never involves any sexual contact, relationships that are exploitive in nature, or relationships that impair a clinician’s objectivity, clinical judgment, or therapeutic effectiveness. However, not all dual relationships are unavoidable or unethical. Pitman is a small town and many clients know each other and the clinicians from the community. Consequently, you may bump into someone you know in the waiting room or into your clinician in the community. Your therapeutic relationship will never be acknowledged without your written consent. Many clients choose a specific clinician because they know of him/her and their stance on a specific topic. Your clinician will discuss with you any potential complexities, difficulties, conflicts, or enhancements that develop due to dual relationships during the course of treatment. It is impossible to know ahead of time or to anticipate these relationships and their effects on treatment. Dual relationships will be discontinued if you or your clinician feel that it is interfering with your treatment. Please communicate any potential dual relationships or ones that develop during the course of treatment with your clinician and they will carefully be discussed with you. Family/Couples Therapy: All members of the family or couple must be present at each session unless the clinician requests otherwise. If this is not possible at any point in time, the session will have to be cancelled and a cancellation fee may apply. During the course of treatment, your clinician may meet with one or more family members without other family members present. These sessions should be viewed as confidential between the clinician and those present in the session. By signing this contract, I agree that the clinician may use his/her judgment as to what information will be shared with family members that are not present. The clinician will not be deceptive or maintain secrets with individual family members, as this is counterproductive to treatment. I also agree that the clinician will not be held liable nor responsible for any information shared with family members. All members of the family/couple must sign this agreement. Confidentiality Policies Office Space, Staff and Personal Health Information (PHI): Xxxx Xxxx, LMFT contracts with South Jersey Psychological and Counseling Services LLC, for professional office space and practice management services. However, Xxxx Xxxx, LMFT maintains separate clinical files and is not in a group practice. By signing this agreement you acknowledge that the office staff of South Jersey Psychological and Counseling Services, LLC will have access to your Personal Health Information (PHI) in order to file claims with insurance companies and for bookkeeping purposes. All office staff have agreed to strictly adhere to all HIPPA rules and regulations for confidentiality. Electronic Communications: Your signature below indicates that you understand that electronic communications (Phone, Email, Fax, Text and other electronic communications) can easily be accessed by unauthorized parties. Please keep this in mind when communicating with your therapist or other parties. Acknowledgment and Receipt of Privacy Practices: Maintaining the privacy of your confidential and protected health information (PHI) is of upmost importance. In conducting business, regards regarding your treatment and services you receive are created. The law requires therapists to give you the Notice of Privacy Practices. It will tell you about the ways in which this practice may use or disclose health information about you. It also describes your rights and obligations regarding the use and disclosure of that information. By signing the signature page, you acknowledge that you have received our Notice of Privacy Practices. Additional Information Regarding Confidentiality: The following section provides you with additional information to that of the Notice of Privacy Practices. Legal Proceedings: In most legal proceedings, we need your written authorization before providing any information about your treatment to attorneys or other interested parties; however, if we are presented with a court order, signed by a judge, we must by law release the information.

Consent to Treatment. I/We hereby authorize and request that Xxxx XxxxXxxxxx Xxxxx, LMFT LPC carry out mental health examinations, treatments, and/or diagnostic procedures which now or during the course of my care are advisable. I/We understand that the purpose of these procedures will be explained to me and be subject to my agreement. I/We understand that I am consenting and agreeing only to those services that the above named provider is qualified to provide within the scope of the provider's license, certification, and training. If the patient is under 18 or unable to consent to treatment, I attest that I am authorized to initiate consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual. Process of Evaluation and Treatment: You will be evaluated based on the information that you (and/or your parent or guardian) provide. You and your therapist will come up with a Treatment Plan based on this information along with the therapist’s assessment of the symptoms and problems presented. Therapy is a unique experience for each person and the results depend greatly on the collaboration between the therapist and the client or clients. You may be asked for your feedback and views on your therapy, its progress, and other aspects of your treatment. Your honesty and openness with your clinician will help determine which approach(es) are the best course of treatment for you. Try to think of the relationship as a partnership focused on you! There is no guarantee that psychotherapy will yield positive or intended results. Please be aware that therapy can sometimes be difficult or even painful but the goal is always to help you to feel better and to live a healthier life. The benefits of therapy may include a reduction in distress, improved interpersonal relationships, and solutions to specific problems. During the course of treatment you may experience uncomfortable feelings while discussing unpleasant aspects of your life. These feelings may include sadness, guilt, anger, frustration, loneliness, helplessness, and insomnia. During the course of treatment, your therapist may use various psychological approaches/treatments based on his/her assessment of what will best treat your problems. These therapeutic approaches may include cognitive behavioral, behavioral, family systems, psychodynamic, developmental, psycho- psycho-educational, or religious-based. Termination: Therapy usually ends when the therapist and the client agree that the treatment goals have been reached. Sometimes life changes bring out further issues to address. At any time during treatment it may be determined that your specific needs require you to be referred to another healthcare provider. Referrals will be provided if it is medically necessary, or if you or your therapist believe that your treatment is not effective in helping you reach your therapeutic goals. You have the right to terminate therapy at any time. Your therapist will provide you with the numbers of treatment providers that you may prefer at your request. If you choose to and authorize in writing, your therapist will assist with you in communicating with the treatment provider of your choice verbally or in writing. Minors: Please note that the records of a minor or person under the care of a legal guardian are accessible to the parent or guardian. The therapist can withhold certain information if it is in the best interest of the child or xxxx for therapeutic or safety reasons. The therapist does not have to disclose information about sexually transmitted diseases, termination of pregnancy, substance abuse, or any other information that your therapist feels would adversely affect the health or welfare of the child, unless the life of the child or xxxx is in danger. By signing this agreement, parents/guardians agree to give up their rights to access the treatment records of minors in order to maintain the therapeutic relationship between the clinician and minor. Parents will be provided only with general information about treatment, unless your clinician perceives that there is a high risk that you will seriously harm yourself or someone else. In this case, your clinician will notify parents of the concern. Parents are encouraged to be active in their minor’s treatment by providing feedback to the clinician during treatment. Parents are also encouraged to communicate any questions or concerns to their minor’s clinician at any time. In treatment involving minor clients, if the client’s parents are not married, both parents must sign the contract or provide a copy of your divorce papers to be reviewed. Dual Relationships: Psychotherapy never involves any sexual contact, relationships that are exploitive in nature, or relationships that impair a clinician’s objectivity, clinical judgment, or therapeutic effectiveness. However, not all dual relationships are unavoidable or unethical. Pitman is a small town and many clients know each other and the clinicians from the community. Consequently, you may bump into someone you know in the waiting room or into your clinician in the community. Your therapeutic relationship will never be acknowledged without your written consent. Many clients choose a specific clinician because they know of him/her and their stance on a specific topic. Your clinician will discuss with you any potential complexities, difficulties, conflicts, or enhancements that develop due to dual relationships during the course of treatment. It is impossible to know ahead of time or to anticipate these relationships and their effects on treatment. Dual relationships will be discontinued if you or your clinician feel that it is interfering with your treatment. Please communicate any potential dual relationships or ones that develop during the course of treatment with your clinician and they will carefully be discussed with you. Family/Couples Therapy: All members of the family or couple must be present at each session unless the clinician requests otherwise. If this is not possible at any point in time, the session will have to be cancelled and a cancellation fee may apply. During the course of treatment, your clinician may meet with one or more family members without other family members present. These sessions should be viewed as confidential between the clinician and those present in the session. By signing this contract, I agree that the clinician may use his/her judgment as to what information will be shared with family members that are not present. The clinician will not be deceptive or maintain secrets with individual family members, as this is counterproductive to treatment. I also agree that the clinician will not be held liable nor responsible for any information shared with family members. All members of the family/couple must sign this agreement. Confidentiality Policies Office Space, Staff and Personal Health Information (PHI): Xxxx XxxxXxxxxx Xxxxx, LMFT LPC contracts with South Jersey Psychological and Counseling Services LLC, for professional office space and practice management services. However, Xxxx XxxxXxxxxx Xxxxx, LMFT LPC maintains separate clinical files and is not in a group practice. By signing this agreement you acknowledge that the office staff of South Jersey Psychological and Counseling Services, LLC will have access to your Personal Health Information (PHI) in order to file claims with insurance companies and for bookkeeping purposes. All office staff have agreed to strictly adhere to all HIPPA rules and regulations for confidentiality. Electronic Communications: Your signature below indicates that you understand that electronic communications (Phone, Email, Fax, Text and other electronic communications) can easily be accessed by unauthorized parties. Please keep this in mind when communicating with your therapist or other parties. Acknowledgment and Receipt of Privacy Practices: Maintaining the privacy of your confidential and protected health information (PHI) is of upmost importance. In conducting business, regards regarding your treatment and services you receive are created. The law requires therapists to give you the Notice of Privacy Practices. It will tell you about the ways in which this practice may use or disclose health information about you. It also describes your rights and obligations regarding the use and disclosure of that information. By signing the signature page, you acknowledge that you have received our Notice of Privacy Practices. Additional Information Regarding Confidentiality: The following section provides you with additional information to that of the Notice of Privacy Practices. Legal Proceedings: In most legal proceedings, we need your written authorization before providing any information about your treatment to attorneys or other interested parties; however, if we are presented with a court order, signed by a judge, we must by law release the information.

Consent to Treatment. I/We hereby authorize and request that Xxxx XxxxXxxxxx Xxxxxxx, LMFT MS, LPC carry out mental health examinations, treatments, treatments and/or diagnostic procedures which now or during the course of my care are advisable. I/We understand that the purpose of these procedures will be explained to me and be subject to my agreement. I/We understand that I am consenting and agreeing only to those services that the above named provider is qualified to provide within the scope of the provider's license, certification, and training. If the patient is under 18 or unable to consent to treatment, I attest that I am authorized to initiate consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual. Process of Evaluation and Evaluation/Treatment: You Like all medical treatments psychotherapy can have benefits and risks. The benefits and risks of your specific treatment will be evaluated based on discussed with you at the information that you (and/or your parent or guardian) provide. You and your therapist will come up with a Treatment Plan based on this information along with the therapist’s assessment of the symptoms and problems presented. Therapy is a unique experience for each person and the results depend greatly on the collaboration between the therapist and the client or clients. You may be asked for your feedback and views on your therapy, its progress, and other aspects onset of your treatment. Your honesty and openness with your clinician will help determine which approach(es) are the best course of treatment for you. Try to think of the relationship as a partnership focused on you! There is no guarantee that psychotherapy will yield positive or intended results. Please be aware that therapy can sometimes be difficult or even painful but the goal is always to help you to feel better and to live a healthier life. The benefits of therapy may include a reduction in distress, improved interpersonal relationships, and solutions to specific problems. During the course of treatment you may experience uncomfortable feelings while discussing unpleasant aspects of your life. These feelings may include sadness, guilt, anger, frustration, loneliness, helplessness, and insomnia. Psychotherapy is not like a medical doctor visit. Instead, it calls for an active effort on your part. In order for psychotherapy to be most effective, you will have to be open with your feelings. You may be asked for your feedback and views on your therapy, its progress, and other aspects of your treatment. Your honesty and openness with your therapist will help determine which approach(es) are the best course of treatment for you. During the course of treatment, your therapist may challenge some of your thoughts, feelings, behavior, assumptions, and perceptions of situations. These challenges may cause unpleasant feelings or feelings of being disappointed. Psychotherapy may also cause changes that were not intended when you began treatment. You may make changes to behavior, interpersonal relationships, employment, substance use, schooling, housing, or other changes. Sometimes a decision or change is viewed positively by one family member and negatively by another. Change and symptom reduction may be fast, but in most cases can take significant time or even be cause for frustration. There is no guarantee that psychotherapy will yield positive or intended results. During the course of treatment, your therapist may use various psychological counseling approaches/treatments based on his/her assessment of what will best treat your problems. These Treatment Plan: During your first few sessions you and your therapist will develop a treatment plan and goals for your treatment based upon his/her understanding of your problem. He/She will discuss the therapeutic approaches objectives, the possible outcomes of therapy, risks/benefits of treatment, and the length of treatment. In order for psychotherapy to be most effective you may include cognitive behavioralbe asked to work on things discussed during treatment, behavioral, family systems, psychodynamic, developmental, psycho- educational, at home. If you have any questions regarding your psychotherapy or religious-basedother treatments that may be available please do not hesitate to ask. Termination: Therapy usually ends when the therapist and the client agree that the treatment goals have been reached. Sometimes life changes bring out further issues to address. At any time during treatment it may be determined that your specific needs require you to be referred to another healthcare provider. Referrals will be provided if it is medically necessary, or if you or your therapist believe that your treatment is not effective in helping you reach your therapeutic goals. You have the right to terminate therapy at any time. Your therapist will provide you with the numbers of treatment providers that you may prefer at your request. If you choose to and authorize in writing, your therapist psychologist will assist with you in communicating with the treatment provider of your choice verbally or in writing. Minors: Please note that the records of a minor or person under the care of a legal guardian are accessible to the parent or guardian. The therapist can withhold certain information if it is in the best interest of the child or xxxx for therapeutic or safety reasons. The therapist does not have to disclose information about sexually transmitted diseases, termination of pregnancy, substance abuse, or any other information that your therapist feels would adversely affect the health or welfare of the child, unless the life of the child or xxxx is in danger. By signing this agreement, parents/guardians agree to give up their rights to access the treatment records of minors in order to maintain the therapeutic relationship between the clinician and minor. Parents will be provided only with general information about treatment, unless your clinician perceives that there is a high risk that you will seriously harm yourself or someone else. In this case, your clinician will notify parents of the concern. Parents are encouraged to be active in their minor’s treatment by providing feedback to the clinician during treatment. Parents are also encouraged to communicate any questions or concerns to their minor’s clinician at any time. In treatment involving minor clients, if the client’s parents are not married, both parents must sign the contract or provide a copy of your divorce papers to be reviewed. Dual Relationships: Psychotherapy never involves any sexual contact, relationships that are exploitive in nature, or relationships that impair a cliniciantherapist’s objectivity, clinical judgment, or therapeutic effectiveness. However, not all dual relationships are unavoidable or unethical. Pitman is a small town and many clients know each other and the clinicians therapist from the community. Consequently, you may bump into someone you know in the waiting room or into your clinician therapist in the community. Your therapeutic relationship will never be acknowledged without your written consent. Many clients choose a specific clinician therapist because they know of him/her and their stance on a specific topic. Your clinician therapist will discuss with you any potential complexities, difficulties, conflicts, or enhancements that develop due to dual relationships during the course of treatment. It is impossible to know ahead of time or to anticipate these relationships and their effects on treatment. Dual relationships will be discontinued if you or your clinician therapist feel that it is interfering with your treatment. Please communicate any potential dual relationships or ones that develop during the course of treatment with your clinician therapist and they will carefully be discussed with you. Family/Couples Therapy: All members of the family or couple must be present at each session unless the clinician therapist requests otherwise. If this is not possible at any point in time, the session will have to be cancelled and a cancellation fee may apply. During the course of treatment, your clinician therapist may meet with one or more family members without other family members present. These sessions should be viewed as confidential between the clinician therapist and those present in the session. By signing this contract, I agree that the clinician therapist may use his/her judgment as to what information will be shared with family members that are not present. The clinician therapist will not be deceptive or maintain secrets with individual family members, as this is counterproductive to treatment. I also agree that the clinician therapist will not be held liable nor responsible for any information shared with family members. All members of the family/couple must sign this agreement. Confidentiality Policies Office SpaceMinors: If you are under eighteen years of age, Staff and Personal Health Information (PHI): Xxxx Xxxxplease be aware that the law gives your parents the right to examine your treatment records. On the other hand, LMFT contracts with South Jersey Psychological and Counseling Services LLCit specifically prohibits parents from seeing records related to sexually transmitted diseases, for professional office space and practice management services. Howevertermination of pregnancy, Xxxx Xxxxsubstance abuse, LMFT maintains separate clinical files and is not in a group practiceor any other information that your therapist feels would adversely affect your health or welfare. By signing this agreement you acknowledge that agreement, parents/guardians agree to give up their rights to access the office staff treatment records of South Jersey Psychological and Counseling Services, LLC will have access to your Personal Health Information (PHI) minors in order to file claims maintain the therapeutic relationship between the therapist and minor. Parents will be provided only with insurance companies and for bookkeeping purposes. All office staff have agreed to strictly adhere to all HIPPA rules and regulations for confidentiality. Electronic Communications: Your signature below indicates general information about treatment, unless your therapist perceives that there is a high risk that you understand that electronic communications (Phonewill seriously harm yourself or someone else. In this case, Email, Fax, Text and other electronic communications) can easily be accessed by unauthorized parties. Please keep this in mind when communicating with your therapist will notify parents of the concern. Parents are encouraged to be active in their minor’s treatment by providing feedback to the therapist during treatment. Parents are also encouraged to communicate any questions or other partiesconcerns to their minor’s therapist at any time. Acknowledgment and Receipt of Privacy Practices: Maintaining In treatment involving minor clients, if the privacy client’s parents are not married, both parents must sign the contract or provide a copy of your confidential and protected health information (PHI) is of upmost importance. In conducting business, regards regarding your treatment and services you receive are created. The law requires therapists divorce papers to give you the Notice of Privacy Practices. It will tell you about the ways in which this practice may use or disclose health information about you. It also describes your rights and obligations regarding the use and disclosure of that information. By signing the signature page, you acknowledge that you have received our Notice of Privacy Practices. Additional Information Regarding Confidentiality: The following section provides you with additional information to that of the Notice of Privacy Practices. Legal Proceedings: In most legal proceedings, we need your written authorization before providing any information about your treatment to attorneys or other interested parties; however, if we are presented with a court order, signed by a judge, we must by law release the informationbe reviewed.

Consent to Treatment. I/We hereby authorize and request that Xxxx XxxxXxxxxx Xxxxxxxxx, LMFT MSW, LCSW carry out mental health examinations, treatments, and/or diagnostic procedures which now or during the course of my care are advisable. I/We understand that the purpose of these procedures will be explained to me and be subject to my agreement. I/We understand that I am consenting and agreeing only to those services that the above named provider is qualified to provide within the scope of the provider's license, certification, and training. If the patient is under 18 or unable to consent to treatment, I attest that I am authorized to initiate consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual. Process of Evaluation and Treatment: You will be evaluated based on the information that you (and/or your parent or guardian) provide. You and your therapist will come up with a Treatment Plan based on this information along with the therapist’s assessment of the symptoms and problems presented. Therapy is a unique experience for each person and the results depend greatly on the collaboration between the therapist and the client or clients. You may be asked for your feedback and views on your therapy, its progress, and other aspects of your treatment. Your honesty and openness with your clinician will help determine which approach(es) are the best course of treatment for you. Try to think of the relationship as a partnership focused on you! There is no guarantee that psychotherapy will yield positive or intended results. Please be aware that therapy can sometimes be difficult or even painful but the goal is always to help you to feel better and to live a healthier life. The benefits of therapy may include a reduction in distress, improved interpersonal relationships, and solutions to specific problems. During the course of treatment you may experience uncomfortable feelings while discussing unpleasant aspects of your life. These feelings may include sadness, guilt, anger, frustration, loneliness, helplessness, and insomnia. During the course of treatment, your therapist may use various psychological approaches/treatments based on his/her assessment of what will best treat your problems. These therapeutic approaches may include cognitive behavioral, behavioral, family systems, psychodynamic, developmental, psycho- psycho-educational, or religious-based. Termination: Therapy usually ends when the therapist and the client agree that the treatment goals have been reached. Sometimes life changes bring out further issues to address. At any time during treatment it may be determined that your specific needs require you to be referred to another healthcare provider. Referrals will be provided if it is medically necessary, or if you or your therapist believe that your treatment is not effective in helping you reach your therapeutic goals. You have the right to terminate therapy at any time. Your therapist will provide you with the numbers of treatment providers that you may prefer at your request. If you choose to and authorize in writing, your therapist will assist with you in communicating with the treatment provider of your choice verbally or in writing. Minors: Please note that the records of a minor or person under the care of a legal guardian are accessible to the parent or guardian. The therapist can withhold certain information if it is in the best interest of the child or xxxx for therapeutic or safety reasons. The therapist does not have to disclose information about sexually transmitted diseases, termination of pregnancy, substance abuse, or any other information that your therapist feels would adversely affect the health or welfare of the child, unless the life of the child or xxxx is in danger. By signing this agreement, parents/guardians agree to give up their rights to access the treatment records of minors in order to maintain the therapeutic relationship between the clinician and minor. Parents will be provided only with general information about treatment, unless your clinician perceives that there is a high risk that you will seriously harm yourself or someone else. In this case, your clinician will notify parents of the concern. Parents are encouraged to be active in their minor’s treatment by providing feedback to the clinician during treatment. Parents are also encouraged to communicate any questions or concerns to their minor’s clinician at any time. In treatment involving minor clients, if the client’s parents are not married, both parents must sign the contract or provide a copy of your divorce papers to be reviewed. Dual Relationships: Psychotherapy never involves any sexual contact, relationships that are exploitive in nature, or relationships that impair a clinician’s objectivity, clinical judgment, or therapeutic effectiveness. However, not all dual relationships are unavoidable or unethical. Pitman is a small town and many clients know each other and the clinicians from the community. Consequently, you may bump into someone you know in the waiting room or into your clinician in the community. Your therapeutic relationship will never be acknowledged without your written consent. Many clients choose a specific clinician because they know of him/her and their stance on a specific topic. Your clinician will discuss with you any potential complexities, difficulties, conflicts, or enhancements that develop due to dual relationships during the course of treatment. It is impossible to know ahead of time or to anticipate these relationships and their effects on treatment. Dual relationships will be discontinued if you or your clinician feel that it is interfering with your treatment. Please communicate any potential dual relationships or ones that develop during the course of treatment with your clinician and they will carefully be discussed with you. Family/Couples Therapy: All members of the family or couple must be present at each session unless the clinician requests otherwise. If this is not possible at any point in time, the session will have to be cancelled and a cancellation fee may apply. During the course of treatment, your clinician may meet with one or more family members without other family members present. These sessions should be viewed as confidential between the clinician and those present in the session. By signing this contract, I agree that the clinician may use his/her judgment as to what information will be shared with family members that are not present. The clinician will not be deceptive or maintain secrets with individual family members, as this is counterproductive to treatment. I also agree that the clinician will not be held liable nor responsible for any information shared with family members. All members of the family/couple must sign this agreement. Confidentiality Policies Office Space, Staff and Personal Health Information (PHI): Xxxx XxxxXxxxxx Xxxxxxxxx, LMFT MSW, LCSW contracts with South Jersey Psychological and Counseling Services LLC, for professional office space and practice management services. However, Xxxx XxxxXxxxxx Xxxxxxxxx, LMFT MSW, LCSW maintains separate clinical files and is not in a group practice. By signing this agreement you acknowledge that the office staff of South Jersey Psychological and Counseling Services, LLC will have access to your Personal Health Information (PHI) in order to file claims with insurance companies and for bookkeeping purposes. All office staff have agreed to strictly adhere to all HIPPA rules and regulations for confidentiality. Electronic Communications: Your signature below indicates that you understand that electronic communications (Phone, Email, Fax, Text and other electronic communications) can easily be accessed by unauthorized parties. Please keep this in mind when communicating with your therapist or other parties. Acknowledgment and Receipt of Privacy Practices: Maintaining the privacy of your confidential and protected health information (PHI) is of upmost importance. In conducting business, regards regarding your treatment and services you receive are created. The law requires therapists to give you the Notice of Privacy Practices. It will tell you about the ways in which this practice may use or disclose health information about you. It also describes your rights and obligations regarding the use and disclosure of that information. By signing the signature page, you acknowledge that you have received our Notice of Privacy Practices. Additional Information Regarding Confidentiality: The following section provides you with additional information to that of the Notice of Privacy Practices. Legal Proceedings: In most legal proceedings, we need your written authorization before providing any information about your treatment to attorneys or other interested parties; however, if we are presented with a court order, signed by a judge, we must by law release the information.