Tides Of Life
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Consent For Services

I, the undersigned, agree and consent to participate in the mental health services offered and provided by Dorothy Rado, ACSW, LCSW, LMFT, a mental health provider as defined by Indiana Law.

I understand that I am consenting and agreeing only to those mental health services that Dorothy Rado is qualified to provide within the scope of her license, certificate and training.

Confidentiality
Tides of Life abides by all Federal and State Confidentiality Laws. These laws require mandatory reporting of suspected abuse or neglect of children/elderly, in a medical emergency and when someone is an imminent danger to self or others. I have received a copy of Tides of Life's Notice of Privacy practices.

Phone And Other Contact Information
In order to provide maximum services to our clients, we may need to contact you by phone, fax, text, internet or mail. Please indicate how we can reach you:
Please call me at this number , you may leave a message.
Please contact me at this number , DO NOT LEAVE A MESSAGE.
Please follow these arrangements to contact me

Payment For Services
I agree to pay for all services provided by Tides of Life at the time of services. I agree to the release of client information necessary to obtain payment from third party payers. This information may be released verbally, in writing, by fax or computer. I hereby authorize payment directly to Tides of Life from third party payers. I understand that third parties are billed as a courtesy. I accept responsibility for payment of all services provided by Tides of Life that are not paid by third party payers regardless of the reason for nonpayment by the third party. I understand a fee will be charged for bounced checks. If my account balance is not paid, I acknowledge responsibility for payment of all legal, court, collection and other costs necessary to obtain payment.

Coverage And Crisis Services
Tides of Life staff are not available 24 hours a day. In the case of an emergency, I will contact 911 or seek the services of the nearest emergency room.

Messages left for Tides of Life are returned within 2 business days. Sometimes technical problems (such as a bad cell connection or spam filters) interfere and we do not receive a message. If I do not receive a response, I agree to re-contact Tides of Life.

Missed Appointments
Attending scheduled appointments is important. A charge may be incurred if you do not cancel your appointment 24 hours in advance. In cases of severe weather, please contact the office to reschedule.

I have read and understand the above statements.
By checking this box and entering my name below I agree that all of the above is true.
Name:   Date: