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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. 

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Consent for Treatment

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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. 

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Services

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Psychotherapy Fees

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Insurance

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Cancellation Policy

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Payment 

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Phone Contact 

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Email and SMS Contact. 

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

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Client Signature    Date 

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