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Welcome to my practice, I am pleased to have the opportunity to witness your personal growth. This form is designed to provide you with information necessary to empower and informed decision to work with me. 

Consent for Treatment

I ______________, hereby provide my consent to participate in an initial consultation and psychotherapy with Christine Mammes LMHC, ERY. I understand that there are limits of confidentiality  including eminent or serious danger to self or others, or in the case of identifiable abuse to a child or persona incapable of caring for themselves ie. the elderly or disables, or sexual misconduct by another mental health professional. In rare circumstances my records may be subject to a subpoena issued by the courts. The aforementioned circumstances will necessitate disclosure to the appropriate authorities. 

Services

Psychotherapy Fees

Insurance

Cancellation Policy

Payment 

Phone Contact 

Email and SMS Contact. 

I have read this form in its enritely and understand and agree to the information contained in it.

Client Signature    Date 

2 Guilles Lane Woodbury, NY | christine@youmatterny.com | Tel: 516-588-0077