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TERMS AND CONDITIONS
HIPPA GUIDELINES
Informed Consent for Telephone Therapy Session Services
for:
Dr. Arlene G. Krieger, Ph.D., L.M.H.C., L.M.F.T., CCS
(disclosure page)
I certify that: 1. I am over 18 years
of age. 2. I am not and have not been told that I need
to be under the care of a physician for a major mental
or emotional illness. 3. I am not receiving individual
counseling or psychotherapy with another practitioner.
4. I am not at present feeling suicidal or homicidal.
5. I accept full responsibility for informing my counselor
immediately if I believe I am becoming seriously depressed,
or I am having thoughts of injuring myself or another
person. I understand that she may contact local emergency
services if she feels my state of mind poses a danger
to myself or others.
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I
understand that: 1. The records and notes from my communications
will be kept confidential except where my therapist is
legally required to release them. 2. My personal information
will be kept confidential. If I decide to use a different
e-mail provider, I need to inform the counselor in advance.
3. My therapist will make every effort to return e-mails
within 48 hours of receipt. 4. I am responsible for payment
in advance for all services. 5. I have read all the information
listed here in the disclosure page and by clicking the
‘I ACCEPT’ button below, I agree to all of
the above. |
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