Sri Educational Society Franchise/Study Center Affiliation Form

  • Franchise /Study Center Registration

    Sri Yoga & Vocational Training Institute / Sri Computer Education(SES)

  • Personal Information

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  • Financial Information

  • How I plan to pay for treatment:*

  • Personal History

  • Are you experiencing any of the following? (Please check all that apply)
  • Have you been treated for any health conditions in the last year?

  • Social History

  • Do you do any of the following? (Please check all that apply)
  • Do any of your family members suffer from these? (Please check all that apply)
  • Working with you to identify presenting issues and develop a plan of care is the goal. However, it is your commitment to identifying personal goals towards which you desire to move and obstacles which may prevent that movement which will, in large part, determine the success of the therapy. If you have a crisis situation develop after hours, call the suicide prevention hotline at (800) 784-2433 or go to your local emergency room.

     

    The privacy regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) require ethical and legal commitment to the confidentiality of your Personal Health Information.

  • Legal Responsibility

  • Under the laws of the India and the state of  Uttar Pradesh your Sri Educational Society (SES) must be kept private. It is also required by law to give you this notice and to follow the terms of this notice while it is in effect.

     

    Changes in these privacy practices are allowed at any time as long as those changes are permitted or required by law. Any changes in these privacy practices will affect how the privacy of your SES is protected, including any SES received about you or created in the course of your therapy. These changes could also affect the protection of the privacy of any of your SES received before the changes. If changes are made, a new notice will be available to you.

  • Communication

  • We are committed to ensuring that your privacy is protected. Should we ask you to provide certain information by which you can be identified when using this website; you can be assured that it will only be used in accordance with this privacy statement.

    We will not intentionally share the contents of any email or information submitted via the internet with any third party. However, due to the nature of electronic communications, we cannot and do not provide any assurances that the contents of your email will not become known or accessible to third parties. We urge you not to provide any confidential information to us via electronic communication. Should you choose to communicate via email, the provider contacted will respond to any emails sent until you request that form of communication to cease. Please take all precautions necessary to secure your email should you choose to use it to contact the provider.

  • For Questions, Concerns or Complaints

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    As a Sri Educational Society by the State of Uttar Pradesh through the Society Registration ACT 1860 I am committed to practice according to the ethics of my profession. You may contact the Ragistrar and/or the secretary of the Uttar Pradesh Department of Society Chits Funds  with questions or to register complaints about any licensed of Sri Educational Society Center.

  • Signature and Submission

  • Please type your name below to indicate consent to treatment.

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