Register

Registration is only required if you do not have a username. Please check your spam & junk mail folders to ensure you have not already received an email with a username and password. If you already have a username log in here

Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

Client Information

/ Middle Initial

( optional )
 

( MM-DD-YYYY )






( for Text Message Reminders )

Bill To Contact

/ Middle Initial







Emergency Contact

First Name
Last Name
Phone
Mobile
Relation
Email

Log in Details

( If client is a minor, the legal guardian must enter their email address below. )



Between 8 and 40 letters and numbers

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )




( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

STATEMENT OF CLIENT RIGHTS AND CONFIDENTIALITY
1. You have the right to treatment, regardless of race, religion, sex, ethnicity, age, or handicap.

2. You have the right to determine who will provide treatment for you. You also have the right to decide not to receive psychotherapy from me. If you wish, I will provide you with the names of other qualified professionals.

3. You have the right to terminate therapy if so desired. I request that you discuss your desire to terminate treatment face to face so we can process your feelings and provide closure.

4. You have the right to ask questions at any time about the therapeutic process and interventions utilized.

5. You have the right to be treated with dignity and respect.

6. You have the right to know the cost of services rendered.

7. You have the right to receive a written statement of your rights.

8. You have the right to receive individualized treatment, including a verbal discussion of our treatment goals and plan.

9. You have the right to have information discussed within our sessions remain confidential. Generally, no one will learn of our work without your specific written permission. However, there are some exceptions. If you would like your insurance company to reimburse you for your therapy, then you must be willing to allow information regarding your treatment, such as treatment goals, prognosis, diagnosis, and progress to be shared with the insurance company and/or gatekeeper organization. In addition, there are some situations in which I am required by law to disclose information irrespective of your consent. They are the following:

a. If you are at risk of harm to yourself.
b. If you seriously threaten to injure or kill another person, I must inform that individual and the authorities.
c. If you reveal information pertaining to either child or elder abuse.
d. If a court subpoenas me to testify about you.

10. You have the right to be protected from physical, sexual and other abuse.

11. You have the right be informed of your progress.
( Type Full Name )