I (We) understand that the counseling services are strictly confidential with the following exceptions.
- A legitimate subpoena by a court of law requires the release of information specified by the subpoena,
- Statement of intent to harm oneself or another may result in notification of the intended victim(s) and appropriate
- Information regarding suspected child of elderly abuse or neglect must be reported as mandated by Florida Statute
- Information regarding treatment of a minor without parental consent may be shares with the parent(s), legal
guardian(s), or legal authorities All information concerning other clients of FIFTH STREET COUNSELING IV, is to be held strictly confidential.
I understand that counselors are not available 24 hours a day and that in a crisis situation the Crisis Line is available for community use. All payments for service rendered is due at the time service is provided. A returned check charge of $35 will be imposed for NSF checks. There are additional charges for letters, court or court-related appearances. Cancellation of a scheduled appointment must be made at l ease 24 HOURS IN ADVANCE of the appointment, or there will be a charge for the missed appointment.
Fees for services are as follows: