Registration Form for Therapy with Deborah Lee

Please complete and sign this registration form or contact me with any questions or issues with the form. Thanks.

Policies and Agreements for Deborah Lee, MS, CNS, CIMHP

Welcome! Here is some important information about my therapy practice. I view our work as a partnership formed to enhance your health and well-being.
I look forward to working with you.

CONFIDENTIALITY

The contents of all counseling sessions and your medical records are confidential. Your records can only be released with your written consent. Additionally, the law requires me to make a report in the following cases: intention to harm oneself or another person, or suspected abuse of another person.

IMPORTANT TELEHEALTH SERVICES INFORMATION

According to the standards for telehealth services, I am unable to work with you if you have any current or past thoughts of suicide, are self-harming, have a severe mental health condition, or have any active alcohol or substance abuse addictions. These policies are in place because it is best to have a local, in-person provider in these circumstances. You are required to be in a safe, private location during the consultation. It is also standard not to communicate via social networks and to limit texting and email to non-clinical information. If you forget or choose to do so, you accept full responsibility for exposing your personal information in this way. I will respond by asking you to call me. This is for your protection and safety.

CANCELLATION POLICY

If you need to reschedule or cancel an appointment, please contact me at least 48 hours in advance. If you give less than 24 hours notice, you will be billed $70 for the missed session if you do not call (do not text) to discuss your circumstances. I may be able to reschedule within the same week.

FINANCIAL POLICY

Clients are expected to pay at each session unless otherwise arranged. There is a $35 charge for all returned checks. If unpaid balances are not paid in 30 days and I need to go to collections, a 30% collection fee will be added to the balance.

EMERGENCIES

Please call 911 or go to your nearest E.R. for immediate attention. You may also contact the National Mental Health Hotline at 1-866-903-3787, the Suicide Prevention line at 988, or your local Crisis number.

Here is the form for you to complete and sign:

First Name

Last Name

Phone

Marital Status

Date of Birth (optional)

Mailing Address

Apartment, suite, etc

City

State

Postal Code

Country

Emergency Contact

Emergency Contact Phone Number

Additional Information

I have read and understand the above policies. My signature below indicates that I agree to participate in therapy or consultation with Deborah Lee, MS, CNS, CIMHP, and am financially responsible for all charges.

Consent

Yes, I agree with the privacy policy and the above policies.

Signature