I,

agree to:

1. Attend when my appointment indicates, unless I’m unable. In that case, I will contact Beautiful Minds Medical 24hrs in advance, unless circumstances indicate otherwise. In that case, I will call as soon as I am able to cancel or reschedule. 

 

2. Arrive on time for all appointments.

 

3. Cooperate with staff and participate, to the best of my ability, in all activities and group scheduled for me.

 

4. Not use or possess street drugs or alcohol before or during my appointment. This is a non-smoking facility. Smoking area is in the part across the parking lot.

 

5. Turn my cell phone to OFF (not vibrate mode) during sessions and I will respect my time in the session by not answering calls or checking messages.

 

6. Refrain from making physical or verbal threats to people or property, such as name calling, put-downs, threating with objects, threatening bodily harm or property destruction.

I,

, hereby acknowledge that I have received the Notice of Privacy Practices. Within these guidelines, at Beautiful Minds Medical, specifically there are five instances in which your right to privacy will be set aside:

A. Your therapist is required by law to report if any participant in therapy, specifically or vaguely disclose(s) information possibly indicating current or past abuse or neglect of a child, dependent adult, or elder.

 

B. Your therapist must notify the local authorities and/or the person(s) in danger if your therapist believes, from information that you disclose, that you are of danger to yourself or to someone else.

 

C. During court proceedings, the Judge’s ruling supersedes your right to confidentiality. The attorney may subpoena your records, take your therapist’s deposition, have your therapist appear in court, or all three. Your therapist must break confidentiality if the Judge makes such an order.

If I am at risk of hurting myself or others outside of sessions, I will call: