You certify as factual that you are 18 years of age or older. If you are not an adult, your parent or guardian must consent in advance to your participation in this therapeutic service. You certify that you are an authorized user of the credit card that you are using to pay for the fees charged for this counseling service. Jed Shlackman, LMHC, shall not be held liable for any incidental, indirect, or other consequential damages or loss arising from the use or inability to use any and all of the professional services offered in this agreement. You certify that you are not suicidal and are not self-destructive or a threat to others. If you become suicidal you will call 911 or seek crisis treatment immediately in your local area, as this service is not intended for emergency treatment interventions. All counseling-related communications with Jed Shlackman, LMHC are treated as privileged and confidential communicatons, in accordance with professional ethics and state laws. There are limited exceptions to this policy as required by law; if it is communicated to the counselor that you are about to do physical harm to yourself or others, or that you are engaged in or witness to “child abuse” or “elder abuse” and other situations as defined in and under local or state laws, the protections afforded by “privileged and confidential communications” do not apply and the counselor is bound by state legislated reporting requirements and ethical principles. In all other cases, your personal information will not be provided to third parties without your consent.
You have the right at any time to report any incidences of child abuse or elder abuse to local and state authorities - in Florida you may call the Department of Children and Families hotline at 1-800-96-ABUSE (1-800-962-2873).
I have read, understand, and agree to the above,
(type name here) ________________________________________________ (date) _______________