Agreement

Agreement

Laurel D. Fraser MA LMFT
This agreement is entered into on Date* by and between Laurel D Fraser MA, LMFT, herein after referred to as therapist, a sole proprietor and having her principle place of business at 1720 E Los Angeles Ave, suite #236, Simi Valley, Ventura county, California and (your name) First Name* Last Name* , herein after referred to as client
Please initial each below, and sign where indicated
Treatment Philosophy

During the initial evaluation period, you and your therapist will clarify together the nature of the problems for which you are seeking treatment; define some treatment goals; and, develop a treatment plan that will help you achieve those goals. Your therapist can review with you what your health plan will cover. The treatment plan may include a referral to an MD for medication, attending support groups, reading selected materials, or completing specific written or verbal assignments. You will participate in the ongoing review of your progress, and together with your therapist, update the treatment/ medication plan as appropriate.
Initial*

Clear
Client/Consumer Rights

You have the right to:

(1) Receive considerate and respectful care in a safe setting

(2) Receive informed consent information including the following:

• Therapist’s qualifications and training

• Diagnosis, treatment plan, and possible risks/side effects of recommended treatment

• Participate in the development and implementation of your treatment plan

• Expected results with or without recommended treatment

• Alternative treatments

• Confidential treatment of all your records and have your personal privacy respected

• The limits of confidentiality

• Give or withhold your consent for treatment

• Receive answers to your questions

• Receive an explanation of financial responsibility

• Receive instructions about filing a complaint whenever you are dissatisfied with

the services provided.
Initial*

Clear
HIPPA Rights

I acknowledge that I am aware of my HIPPA rights and in the interest saving trees, a copy of the HIPPA law is available to me upon request.
Initial*

Clear
I have read the statements above, and fully understand my rights.
Name*

First NameLast Name
Client or Guardian Signature*

Clear
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty: