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Contract - 2
are responsible for full payment of our agreed fee. It is important for you to find out
exactly what services are covered by your policy.
Contacting Me: You may leave a voicemail message at (317) 750-1177 or email me at
[email protected]. I make every effort to respond to you within 24 hours with the
exception of weekends and holidays. If you are in a crisis and I am not available for an
extended time, please call the Indianapolis Crisis Center immediately at (317) 251-
7575.
Professional Records and Confidentiality: Both the laws and the standards of my
profession require that I keep appropriate treatment records and that I safeguard your
privacy. Information will be shared only with those persons you approve of with your
signature on a “Consent to Release Confidential Information” form. The following
circumstances are necessary exceptions:
1) When there is a serious threat to my health and safety or the health and
safety of you or another individual I am legally obligated to contact the
appropriate authorities including Child Protective Services for suspected
abuse or neglect.
2) If your account ends up being sent to a collections agency, a copy of your
intake form and invoice will be released as part of this process. No other
clinical information will be released.
3) If I am subpoenaed for legal or court proceedings, information will be shared
as needed; however, I do not agree with therapists being called to court
particularly in cases of divorce.
4) No authorization is required when verbal permission is given to speak with
family members who are directly involved with your treatment.
I have read and agree to the above terms of counseling services with Keirsten J.
Roath.
________________________________________
Client Name – Printed
________________________________________ __________________
Client Name – Signature Date
________________________________________________
Parent or Guardian Signature if Client is a Minor
Counseling Services Agreement Page 2
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