1. I consent to participate in counseling services offered by Mel Langston Professional Services, Inc. and understand that I am consenting and agreeing only to those services that Mel Langston, PhD is qualified to provide within the scope of her license, certification, and training. (Please see Education, Credentials, Specializations, Resume).
2. I acknowledge that I have reviewed, signed and submitted this Consent for Services.
3. I acknowledge that I have reviewed HIPAA Privacy Laws and Confidentiality Practices.
4. I understand that email, text, telephone, and video counseling services have limitations, as well as benefits.
5. I understand that video or telephone counseling is not appropriate if I am experiencing suicidal or homicidal thoughts. If a life-threatening crisis should occur, I agree to contact a Crisis Line, call 911, or go to a hospital emergency room.
6. I understand that video or telephone counseling is not a substitute for medication prescribed by my physician (See FAQs).
Your signature below indicates that you have read and understand 1) this Consent for Services form, 2) HIPAA Privacy Laws and Confidentiality Practices and how information about you may be disclosed, and 3) that you consent to treatment.
Please sign and return by mail or at first session. Thank you.
Name ___________________________
Date ___________________________
