Office Policy Form Freedom of Provider Choice: I have been informed and understand I have a freedom of choice of Providers available to me. Limits of Confidentiality: All information that you disclose within therapy sessions is confidential and will not be revealed without your written permission (or your parents’ permission if you are under 18 years old). Disclosure, however, may be authorized or required by law , listed below. PA Duty to Warn and Ethical Guidelines are strictly maintained. Disclosure may also be required pursuant to a legal proceeding. • where there is a reasonable suspicion of child abuse or elder adult physical abuse; • where there is a reasonable suspicion that you may present a danger of violence to others; • where there is a reasonable suspicion that you are likely to harm yourself unless protective measures are taken.Cancellation: A minimum of 48 hours’ notice is required for rescheduling or cancellation of an appointment. A fee, equal to half your regular session self-pay fee will be charged for missed sessions without such notification. Associated regular insurance co-pay fees will be billed as well. Two no-show appointments in total, and/or three cancellations will result in termination of services. Following an initial intake, an appointment must be made within 10 days for a session to be held within a month, or a discharge letter will be sent. Our office does not give reminder calls.Professional Relationship: The helping relationship is of a professional nature. Treatment goals will be mutually agreed upon. Respect and non-violence will be strictly maintained. Termination will be at completion of therapeutic goals or at Business Managers request if policies are not maintained. Termination by the clinical practitioner may also occur if therapeutic treatments no longer meet the clients’ needs or interests. Appropriate clinical and professional referrals will made and in a timely manner. All grievances will be initially discussed with direct clinical practitioner.No Harm: While in therapy, individuals commit to no harm of self or others. If there is a need for assistance to maintain this agreement, individuals will voluntarily contact emergency help, including the local Crisis Line at 717-264-2555 or proceed to your nearest emergency roomParent / Guardian SignatureDated MM slash DD slash YYYY Client SignatureDated MM slash DD slash YYYY Office Witness (For Office Use Only)Dated MM slash DD slash YYYY
