Important Disclaimer
Please note that although this information is being collected by Barb Shepard, LMHC, it is being collected solely for legislative advocacy purposes and not as part of the provision of mental health services.
Information submitted through this form is not protected health information under HIPAA, is not confidential, and does not create a therapist-client or any other therapeutic relationship with Barb Shepard, LMHC.
By voluntarily submitting this form, you acknowledge and understand that the information you provide may be shared, in whole or in part, with members of the New York State Legislature, legislative staff, governmental agencies, advocacy organizations, or other individuals involved in legislative efforts related to PANS/PANDAS. Once this information has been shared, Barb Shepard, LMHC has no control over how it may be further used, shared, or redisclosed by recipients.
Participation is entirely voluntary. You are under no obligation to complete this form and should use your own judgment and discretion regarding what information you choose to disclose. Please do not include any information you would not be comfortable having shared in support of these legislative efforts.
If you have any questions, concerns, or would like clarification about how your information may be used before submitting this form, please reach out prior to completing it.