Common Contracts
2 similar null contracts
Hicks Counseling ServicesJanuary 21st, 2017
Scope of Confidentiality: I understand that my disclosures to the staff of Hicks Counseling Services (HCS) will not be revealed to outside parties except in the following instances: 1) Where my written permission has been granted; 2) Where my physical safety or the physical safety of another person is threatened; 3) Where evidence is given of physical or sexual abuse; 4) Where records are subpoenaed by a judge. I also understand and agree that for the purpose of ensuring highest quality care, with my agreement my case may be discussed in conference or supervision with other psychologists or mental health professionals. If I should default in paying the balance of my account with HCS, then I understand that identifying information and dates of service may be disclosed if litigation or collection action becomes necessary.
Hicks Counseling ServicesJanuary 21st, 2017
Scope of Confidentiality: I understand that my disclosures to the staff of Hicks Counseling Services (HCS) will not be revealed to outside parties except in the following instances: 1) Where my written permission has been granted; 2) Where my physical safety or the physical safety of another person is threatened; 3) Where evidence is given of physical or sexual abuse; 4) Where records are subpoenaed by a judge. I also understand and agree that for the purpose of ensuring highest quality care, with my agreement my case may be discussed in conference or supervision with other psychologists or mental health professionals. If I should default in paying the balance of my account with HCS, then I understand that identifying information and dates of service may be disclosed if litigation or collection action becomes necessary.
