Athlete Intake Information Logo
  • Athlete Intake Information

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  • Mental Performance Training History

  • Sport/Activity Pertinent Information

  • Confidentiality Statement

    Information about you, including professional records that are required by laws and the standards of my profession, will be kept strictly confidential. Please be aware of the following exceptions to the law:

    1. If you present a danger to yourself or others, I have a legal requirement to help keep you safe and a duty to warn potential victims.

    2. If you identify any known or suspected abuse of a child, an elder, or person with a disability, I am required by law to report such abuse to the appropriate agency.

    3. If ordered by a judge in a court of law, I am required to provide access to your records; however, I would first make every legal effort to protect your confidentiality.

    Please ask any questions necessary regarding the limits of confidentiality. If you no further questions, please sign below to indicate that you have read this statement and understand the contents. 

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  • Consent to Consultation

    I have read and discussed the Confidentiality Statement and understand that this is not licensed therapy or counseling. I am willingly consenting to working with Neil Place and Oreka Fitness under those stated parameters. 

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