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Consent & HIPPA Form

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Effective Date: 02/19/2025
Last Updated: 02/19/2025

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1. Informed Consent for Services

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I acknowledge and agree to the following:

  • I voluntarily consent to participate in therapy services and/or online wellness programs provided by Clinical Confessions, LLC.

  • I understand that therapy sessions are intended for personal growth and well-being and are not a substitute for emergency medical or psychiatric care.

  • I acknowledge that results may vary, and no specific outcomes are guaranteed.

  • I understand that all therapy sessions are non-refundable once booked and confirmed, and rescheduling requires at least 24 hours' notice before the session.

 

3. Confidentiality & HIPAA Notice

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Your privacy is important to us. Clinical Confessions, LLC follows all regulations under the Health Insurance Portability and Accountability Act (HIPAA) to protect your health information.

Your Rights Under HIPAA

  • Right to Access: You may request copies of your records.

  • Right to Amend: You can request corrections to inaccurate or incomplete information.

  • Right to Confidentiality: Your personal and health information will not be shared without your consent, except as required by law.

  • Right to Restrict Use: You may request limitations on how your information is used or disclosed.

 

Situations Where Confidentiality May Be Broken

By law, we may be required to release information if:

  • You are at immediate risk of harm to yourself or others.

  • There is suspected child abuse, elder abuse, or neglect.

  • We receive a court order requiring disclosure.

 

4. Telehealth & Online Therapy Consent

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If receiving therapy or coaching virtually, I acknowledge and understand:

  • Sessions will be conducted via a secure online platform.

  • I am responsible for ensuring privacy on my end during sessions.

  • Technical issues may arise, and a backup communication plan may be needed.

  • Online therapy is subject to HIPAA regulations, ensuring the protection of my information.

 

5. Communication & Electronic Correspondence

 

I consent to receiving emails, phone calls, and text messages from Clinical Confessions, LLC for appointment reminders, wellness updates, and relevant service information.
I understand that:

  • Emails and texts may not be fully secure and may carry privacy risks.

  • I may opt out of non-essential communications at any time.

 

6. Acknowledgment & Signature

 

I acknowledge that I have read, understand, and agree to the terms outlined in this consent and HIPAA authorization form.

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By checking the box at the time of booking and payment, you acknowledge that you have read, understood, and agreed to all policies, including our Terms & Conditions, Privacy Policy, Refund Policy, and Consent & HIPAA Authorization. Your consent is documented and legally binding upon submission.

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