Acknowledgement and Receipt
By submitting the below I acknowledge that I have read and fully understand the following:
I have full access online to the following forms. I understand that I can request a hardcopy of the following forms and it will be provided by Harvest House. I understand that I have the right to discuss thoroughly and ask any questions about the forms with my Provider:
Informed Consent for Psychotherapy (updated March 23, 2015)
HIPAA (updated December 4, 2013)
Harvest House Marriage and Family Therapy, P.C. uses and accesses technology including but not limited to: internet, email, voicemail, cellular phones, wireless phones, texting, facsimiles. Harvest House works to ensure that electronic information is protected from computer viruses and kept confidential from unauthorized intruders. Reasonable security measures are taken but confidentiality can not be assured.
If you would like to not be connected by email or texting, please indicate below. Further, you agree not to contact me in this manner but will rely on phone or in person contact. If you do contact me via email or texting, you understand that this constitutes a revocation of any request from you to not use this form of communication.