Litigation Limitation. Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that, should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney(s), nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.
Litigation Limitation. Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on Dr. Zed to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.
Litigation Limitation. Due to the nature of psychotherapy with regard to the therapeutic process and confidential nature of the work, I/we agree that should there be legal proceedings (such as but not limited to divorce and custody disputes, injuries, lawsuits, etc.) that neither me (client), nor my attorney, nor anyone else acting on my behalf will call on the clinician to testify in court or in any other legal proceedings, nor will the disclosure of psychotherapy records be requested. Professional Records: The laws and standards of your clinician’s profession require that he/she prepare and maintain treatment records. You are entitled to receive a copy of your records, or a summary from your clinician, unless your clinician believes in his or her professional judgment that release of such information would adversely affect your health and well-being. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we will be happy to review them with you so that we can discuss the contents. You will be charged an appropriate fee for any professional time we spend in reviewing records with you. In addition, we will charge for our costs in providing copies of the records. Emergency Procedures: If you need to contact our office between sessions, please call 000-000-0000 x000 and leave a message. I will do my best to return all phone calls as quickly as possible. In the event of an emergency, please call 911 or call the area Crisis Center at 000-000-0000. You can also go to your nearest Crisis Center or hospital Emergency Room. You may also consider calling the 24-hour “NJ Suicide Prevention Hopeline” at 000- 000-0000 for immediate information and resources. Mediation and Arbitration: All disputes arising out of our relationship to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a precondition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of the clinician and client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any resolved controversy related to this agreement should be submitted to and settled by binding arbitration in Gloucester County, NJ in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the forgoing, in the ev...
Litigation Limitation. Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on Xx. Xxxxxxxx to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested. Consultation: Xx. Xxxxxxxx consults regularly with other professionals regarding his/her clients; however, the client’s name or other identifying information is never mentioned. The client’s identity remains completely anonymous, and confidentiality is fully maintained. * Considering all of the above exclusions, if it is still appropriate, upon your request, Xx. Xxxxxxxx will release information to any agency/person you specify unless Xx. Xxxxxxxx concludes that releasing such information might be harmful in any way. TELEPHONE & EMERGENCY PROCEDURES: If you need to contact Xx. Xxxxxxxx between sessions, please leave a message on the voice mail answering service (000)000-0000 and your call will be returned as soon as possible. Xx. Xxxxxxxx checks his messages a few times a day, unless he is out of town. If an emergency situation arises, please indicate it clearly in your message. If you need to talk to someone right away, you can call Xx. Xxxxxxxx at (000)000-0000 the 24-hour crisis line (000)000-0000, the Police (911), or the 24-hour Psych. Emergency at Loma Xxxxx Behavioral Medicine Center (000)000-0000 or go to the nearest emergency room. PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the standard fee of $140.00 per 45 minute session at the end of each session unless other arrangements have been made. Telephone conversations, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed otherwise. Please notify Xx. Xxxxxxxx if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, Xx. Xxxxxxxx will provide you with a copy of your receipt on a monthly ...
Litigation Limitation. Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.) neither you (client), nor your attorney, nor anyone else acting on your behalf will call upon Xx. Xxxxxxxxx to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested. If you become involved in a divorce or custody dispute, understand that you should hire a different mental health professional for reasons such as: Xx. Xxxxxxxxx statements will be seen as biased in your favor, and might affect the therapy relationship.
Litigation Limitation. Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matter which may be of a confidential nature, you agree that should there be legal proceedings (such as custody disputes, injuries, lawsuits, etc.), neither you (clients) nor your attorneys, nor anyone else acting on your behalf, will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested. Consultation: I consult regularly with other professionals regarding my clients; however, neither clients’ names, nor any other identifying information, are ever mentioned. My client’s identity remains completely anonymous and confidentiality is fully maintained.
Litigation Limitation. Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that, should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney(s), nor anyone else acting on your behalf will call on Xx. Xxxxx to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon. In some proceedings, however, a judge may determine that the client has expressly or implicitly waived the right to confidentiality, in which case a therapist might be required to give testimony. If any of these situations were to occur, Xx. Xxxxx will make every effort to fully discuss them with you before taking any action. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Xx. Xxxxx.
Litigation Limitation. Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters, which may be of confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc .) neither you nor your attorney, nor anyone else acting on your behalf will call me to testify in court or at any proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon in advance. If agreed upon, additional fees will apply for testifying in legal proceedings.
Litigation Limitation. Due to the nature of the Counseling process and the fact that it often involves making a full disclosure with regard to many matters that may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.), neither you, your attorney, nor anyone else acting on your behalf will call on your counselor to testify in court or at any other proceeding, nor will a disclosure of the Counseling records be requested. We do not offer custody, psychiatric, or psychological evaluations. In addition, you, the counselee sought biblical counseling as such adhered to by Grace Community Church, a non-profit religious organization. You, as the Counselee hereby acknowledge your understanding of the following condition and further release from liability Grace Community Church, its agents or employees, from any claim arising from the undersigned participation in the above mentioned biblical counseling program, the same being identified as follows: This is a church-based ministry providing counseling which supports spiritual, emotional, and mental health. The counseling center is part of a non-profit ministry. In accordance with I Corinthians 6 and other passages, we require anyone receiving counseling from GCC to agree to release GCC, its pastors, agents, employees, counseling supervisor(s), and lay counselors from liability. Your signature at the end of this form is your agreement to these conditions.
Litigation Limitation. Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters that may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested. Consultation I consult regularly with other professionals regarding my clients; however, the client’s name or other identifying information is never mentioned. Considering all of the above exclusions, if it is still appropriate, upon your request, I will not release information to any agency/person you specify unless I conclude that not releasing such information might be harmful in any way.
