Hello!
I am looking forward to working together.
This form is a legally binding agreement for therapy services.
It contains important information about my professional services and business policies. It also contains information about my policies and practices to protect the privacy of your health information.
Please read through each item carefully and let me know if you have any questions or concerns.
By electronically signing this document, you will be stating that you were provided with this information and it will represent a binding agreement between us.
Traditionally, this would be provided as a paper form when we first meet, but this form will allow you to complete it wherever is most convenient for you: on your cell, on your tablet, on your computer, in line at the coffee shop or sitting on your sofa with some hot tea.
If at any point, you need to take a break, please do so. Take care of yourself when completing this. And, if you want your answers to auto-save, make sure you're logged into a Google/Gmail account when you access this form.
I have set up this form to automatically pull your email address; you will also automatically receive a copy of your responses, so please choose an email account that is CONFIDENTIAL and PRIVATE. Please do NOT use a work email or a shared email with a family member or spouse. Please use a private email, so that we can maintain confidentiality.
This form will take you approximately 30 minutes; please set aside time to fill it out without interruptions.
I am here if you have any questions. If so, please email me at
hello@jamielynnmayberry.com.
See you soon,
Jamie
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Jamie Mayberry Johnson, LCSW
Jamie Lynn Mayberry, Inc.
NICU Louisiana
8814 Veterans Memorial Blvd
STE 3 # 229
Metairie, LA 70003
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© This document and its contents are protected by National and International Copyright Laws. All Rights Reserved. You do not have permission to copy, download, distribute, share, sell, or use for any other use than your personal use in the context of potentially engaging in therapy with Jamie Lynn Mayberry Johnson, LCSW.
