Clinician Disclosure Statement Confirmation of Review

A Better Way Counseling Service, LLC

Clinician Disclosure Statement Confirmation of Review
Client's Full Name*

First NameLast Name
Date*

MonthDayYear
Date
Therapist Name*
Therapist/Clinician Name*

First NameLast Name
I am signing to agree that I was able to review the dislosure statement for the above therapist, whom, I will recieve services from A Better Way Counseling Services, LLC. I acknowledge that a copy of this document is always available to me upon request. I agree to all the sections of the disclosure statement, including:
(Please check all below*)*

I have read and reviewed my rights regarding my Protected Health Information (PHI).I have read and reviewed the terms of consent.I have read and reviewed the financial terms & conditions.I have read and reviewed email and phone messaging informed consent.(*Only if applicable) I am the legal guardian (managing conservator) of the minor. With the understanding of the requirements, you grant permission
Client/Guardian Signature*

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A Better Way Counseling Service, LLC