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Disclosure Statements for All Therapists

Your therapist's Disclosure Statement may be read, downloaded and printed from this page.  

The statement is generally three pages. Page one is introductory.  Page two covers Disclosure and Confidentiality.  Page three is for signatures.

Two copies of the statement will print in sequence--one for you and one for the therapist (NOTE:The client copy has all three pages, the therapist copy has only the Disclosure and Signature pages).  Please read the Disclosure Statement, print your name in the space for ‘client name,’ then sign and date the form (in two places) on the last page. If more than one person is coming to counseling, each person needs to read and double-sign the last page.  Repeat this process on the second copy. Your therapist will sign and return one copy to you.  

Notice of HIPAA Privacy Practices (one copy for you).  Please read this and keep it for your records.

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Tita Subercaseaux (in Spanish) >   
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