An important aspect of counseling is coordination with other individuals or community agencies with whom you have worked with in the past or are working with in the present. It is also necessary at times to communicate with insurance companies to facilitate reimbursement.

I am committed to safeguarding your rights and well-being. This information will be held private and confidential. You have the right to withdraw your consent at any time by sending written notification to me.

Unless sooner revoked, this consent expires at the time of termination of services.

I will not condition your treatment on whether you give authorization for the requested disclosure.