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Congratulations!
Based on your answers, it looks like you are qualified to receive treatment from University Elite.  Please read carefully, and accept our terms of service as listed below. Completing this form will register your private account with University Elite, & allow you to schedule appointments.
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This email will be used to log into University Elite every time you schedule a session.
This password will be used to log into University Elite every time you schedule a session.
If you are seeking care for a minor, you must understand and accept these terms as the legal guardian.
Psychiatric treatment and psychotherapy are confidential, with important exceptions: 1. Information may be released to designated parties by written authorization of clients or legal guardians. 2. Mental health providers are required to report suspected past or present abuse or neglect of children, adults, and elders, to the authorities, including Child Protective Services, Adult Protective Services and law enforcement, based on information provided by the client or collateral sources. 3. If clients participate in treatment in compliance with a court order, therapists are required to release information to the relevant court, social service, or probation departments. 4. Mental health providers are required to release information obtained from clients or from collateral sources (other individuals involved in a client’s psychotherapy, such as parents, guardians, spouses) to appropriate authorities when such disclosure may help to avert danger to a psychotherapy client or to others, e.g.; imminent risk of suicide, homicide, or destruction of property that could endanger others. 5. Therapists are required to provide information in response to court orders as determined by a judge. In some proceedings, courts order the entire psychotherapy record. 6. We reserve the right to release financial information to a collections agency, attorney, or small claims court, if you are delinquent on paying your bill.
have read and understood the office policies of University Elite. I consent to an evaluation and treatment planning. I understand that treatment sessions are used to verify that the doctor’s resources meet the patient’s needs. I understand that in rare cases, completion of the evaluation and treatment planning may reveal that the patient’s needs may exceed the doctor’s resources. In these rare cases, the recommendation may be to find a different provider/clinic that has the needed resources. I commit to being open and honest during the course of the evaluation, treatment planning and treatment sessions in order to receive the most accurate treatment options for my problems.
This is a legally binding signature. By submitting this form, you are legally stating that the information you have submitted is true and accurate. You will be taken to a page where you can choose your Psychiatrist or Psychologist and then schedule your first session. By submitting this form, you are agreeing to University Elite's Terms of Service and Privacy Policy. University Elite is a HIPPA compliant entity. Your information will be protected as guided by HIPPA regulations and will not be shared with third parties for marketing or other purposes.
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