Please print page and mail the filled out form to the above address.

This statement is intended to highlight your rights, help you remain in control, and remind you that you are the major partner in your emotional health care.

IN THIS OFFICE YOU HAVE THE FOLLOWING RIGHTS:
• You have the right to speak openly and freely at all times. What you have to say is considered vitally important to your treatment and your therapy success.
• You have the right to strict confidentiality, to be treated with dignity and respect at all times, and to a second opinion if you so desire.
• You have the right to a competent, caring and communicative therapist.
• If you find that I do not meet your needs, another therapist can be provided for you - if you so desire.

If you have any questions or concerns about any of this information, please feel free to discuss them with your therapist.

By signing below you are stating that you have read and understand this information.

Name:_____________________________ Date:____________