Signature Page

 

Please print and bring with you to sign at our first visit.

 

 

 

 

I have read and understand the following documents and have been given the opportunity to discuss all my questions about them with Dr. Shields.

 

Psychotherapist-Patient Services Agreement


Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information (HIPPA)

 

 

Name:

 

 

Signature:

 

 

Date:

© 2013 by Katie Marino