REGULATION OF MENTAL HEALTH PROFESSIONALS IN COLORADO:

1. Hedman Counseling, PC is located at 4297 Austin Bluffs Parkway, Suite 204; Colorado Springs, CO 80918; 719-235-5325. The certified yoga and dance teacher located at Hedman Counseling, PC is Rachael Fromkin. Rachael earned a Bachelor of Arts in Communications from DePaul University in 2013 and will earn a Master's degree in Clinical Mental Health Counseling from the University of Colorado at Colorado Springs in 2020. Rachael has been a Certified Yoga Instructor since 2016 and has been teaching dance since 2011.

2. Everyone fifteen (15) years and older must sign this disclosure statement. A parent or legal guardian with the authority to consent to yoga and/or dance services for their minor child/ren, must sign this disclosure statement on behalf of their minor child under the age of fifteen (15) years old. This disclosure statement contains the policies and procedures of Hedman Counseling, PC/Rachael Fromkin and is HIPAA compliant. No medical or psychotherapeutic information, or any other information related to your privacy, will be revealed without your permission unless mandated by Colorado law and Federal regulations (42 C.F.R. Part 2 and Title 25, Article 4, Part 14 and Title 25, Article 1, Part 1, CRS and the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 142, 160, 162 and 164).

3. The Colorado Department of Regulatory Agencies ("DORA"), Division of Professions and Occupations ("DOPO") has the general responsibility of regulating the practice of Licensed Psychologists, Licensed Social Workers, Licensed Professional Counselors, Licensed Marriage and Family Therapists, Certified and Licensed Addiction Counselors, and registered individuals who practice psychotherapy. The agency within DORA that specifically has responsibility is the Mental Health Section, 1560 Broadway, Suite #1350, Denver, CO 80202, (303) 894-2291 or (303) 894-7800; DORA_MentalHealthBoard@state.co.us.  The State Board of Registered Psychotherapists regulates Registered Psychotherapists, and can be reached at the address listed above. Clients are encouraged, but not required, to resolve any grievances through Hedman Counseling, PC/Rachael Fromkin's internal process.

4. You, as a client, may revoke your consent to treatment or the release or disclosure of confidential information at any time in writing and given to your therapist.

5. Levels of Psychotherapy Regulation in Colorado include Licensing (requires minimum education, experience, and examination qualifications), Certification (requires minimum training, experience, and for certain levels, examination qualifications), and Registered Psychotherapist (does not require minimum education, experience, or examination qualifications.) All levels of regulation require passing a jurisprudence take-home examination.

Certified Addiction Counselor I (CAC I) must be a high school graduate, complete required training hours and 1,000 hours of supervised experience. Certified Addiction Counselor II (CAC II) must complete additional required training hours and 2,000 hours of supervised experience. Certified Addiction Counselor III (CAC III) must have a bachelor's degree in behavioral health, complete additional required training hours and 2,000 hours of supervised experience. Licensed Addiction Counselor must have a clinical master's degree and meet the CAC III requirements. Licensed Social Worker must hold a masters degree in social work.  Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure. Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a masters degree in their profession and have two years of post-masters supervision. A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision. Registered Psychotherapist is a psychotherapist listed in Colorado's database and is authorized by law to practice psychotherapy in Colorado but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state. Registered psychotherapists are required to take the jurisprudence exam.

6. I am a Certified Yoga Instructor, listed in the International Yoga Alliance, and thereby authorized to practice yoga instruction. There are no official/required governing boards of dance instruction with which to register. I seek ongoing education and consultation with other professionals in the fields of yoga, dance and mental health.

CLIENT RIGHTS AND IMPORTANT INFORMATION:

As a client you are entitled to receive information from me about my methods of instruction, the techniques I use, the duration of your practice, if I can determine it, and my fee structure.  Please ask if you would like to receive this information.

Fees:

1. My fee structure, services, and fee policy are outlined as follows:

$100.00 per clinical hour

I also offer a reduced fee structure for those with significant financial need when sessions are available. If you are unable to pay the standard hourly fee, please talk to me about alternative payment options.

Administrative or research services required for adjunct services outside of Hedman Counseling Center will be charged at $120.00 per hour.

It is the policy of my practice to collect all fees at the time of service, unless you make arrangements for payment and we both agree to such an arrangement. In addition, I request that you fill out a "Credit Card Authorization" form to keep in your file. All accounts that are not paid within thirty (30) days from the date of service shall be considered past due. If your account is past due, please be advised that I may be obligated to turn past due accounts over to a collection agency or seek collection with a civil court action. By signing below, you agree that I may seek payment for your unpaid bill(s) with the assistance of a collections agency. Should this occur, I will provide the collection agency or Court with your Name, Address, Phone Number, and any other directory information, including dates of service or any other information requested by the collection agency or Court deemed necessary to collect the past due account. I will not disclose more information than necessary to collect the past due account. I will notify you of my intention to turn your account over to a collection agency or the Court by sending such notice to your last known address.

Therapy fees and treatment are based on a 45-55 minute clinical hour instead of a 60 minute clock hour so that I may review my notes and assessments on your behalf.

I am not a Medicaid provider. If you have Medicaid coverage that includes mental health services, I am not able to offer mental health services to you.

Legal Services incurred on your behalf are charged at a higher rate including but not limited to: attorney fees I may incur in preparing for or complying with the requested legal services, testimony related matters like case research, report writing, travel, depositions, actual testimony, cross examination time, and courtroom waiting time. The higher fee is $500.00 per hour.

Hedman Counseling is proud to support the non-profit organization Love146. For every counseling session you purchase with Hedman Counseling, 2% of the net proceeds are donated to Love146.

Restrictions on Uses:

2. You are entitled to request restrictions on certain uses and disclosures of protected health information as provided by 45 CFR 164.522(a), however Hedman Counseling, PC/Rachael Fromkin is not required to agree to a restriction request. Please review Hedman Counseling, PC/Rachael Fromkin's Notice of Privacy Policies for more information.

Second Opinion and Termination:

3. You are entitled to seek a second opinion from another yoga instructor or dance instructor or terminate services at any time.

Sexual Intimacy:

4. In a professional relationship (such as psychotherapy), sexual intimacy between a psychotherapist and a client is never appropriate.  If sexual intimacy occurs it should be reported to DORA at (303) 894-2291, Mental Health Section, 1560 Broadway, Suite 1350, Denver, Colorado 80202; State Board of Registered Psychotherapists.

Confidentiality:

5. Generally speaking, the information provided by and to a client during sessions is legally confidential if the psychotherapist is a Licensed Psychologist, Licensed Social Worker, Licensed Professional Counselor, Licensed Marriage and Family Therapist, Certified and Licensed Addiction Counselor, or a Registered Psychotherapist. If the information is legally confidential, the psychotherapist cannot be forced to disclose the information without the client's consent or in any court of competent jurisdiction in the State of Colorado without the consent of the person to whom the testimony sought relates.

6. There are exceptions to this general rule of legal confidentiality. These exceptions are listed in the Colorado statutes, C.R.S. 12-43-218. You should be aware that provisions concerning disclosure of confidential communications does not apply to any delinquency or criminal proceedings, except as provided in C.R.S 13-90-107. There are additional exceptions that I will identify to you as the situations arise during treatment or in our professional relationship. For example, I am required to report child abuse or neglect situations; I am required to report the abuse or exploitation of an at-risk adult or elder or the imminent risk of abuse or exploitation; if I determine that you are a danger to yourself or others, including those identifiable by their association with a specific location or entity, I am required to disclose such information to the appropriate authorities or to warn the party, location, or entity you have threatened;  if you become gravely disabled, I am required to report this to the appropriate authorities. I may also disclose confidential information in the course of supervision or consultation in accordance with my policies and procedures, in the investigation of a complaint or civil suit filed against me, or if I am ordered by a court of competent jurisdiction to disclose such information. You should also be aware that if you should communicate any information involving a threat to yourself or to others, I may be required to take immediate action to protect you or others from harm. In addition, there may be other exceptions to confidentiality as provided by HIPAA regulations and other Federal and/or Colorado laws and regulations that may apply.

Additionally, although confidentiality extends to communications by text, email, telephone, and/or other electronic means, I cannot guarantee that those communications will be kept confidential and/or that a third-party may not access our communications. Even though I may utilize state of the art encryption methods, firewalls, and back-up systems to help secure our communication, there is a risk that our electronic or telephone communications may be compromised, unsecured, and/or accessed by a third-party. Please review and fill out Hedman Counseling, PC/Rachael Fromkin's Consent for Communication of Protected Health Information by Unsecure Transmissions.

"No Secrets" Policy:

7. When treating a couple or a family, the couple or family is considered to be the client. At times, it may be necessary to have a private session with an individual member of that couple or family. There may also be times when an individual member of the couple or family chooses to share information in a different manner that does not include other members of the couple or family (i.e on a telephone call, via email, or via private conversation). In general, what is said in these individual conversations is considered confidential and will not be disclosed to any third party unless your instructor is required to do so by law. However, in the event that you disclose information that is directly related to the treatment of the couple or family it may be necessary to share that information with the other members of the couple or the family in order to facilitate the healing process.  Your instructor will use their best judgment as to whether, when, and to what extent such disclosures will be made. If appropriate, your instructor will first give the individual the opportunity to make the disclosure themselves.  This "no secrets" policy is intended to allow your instructor to continue to treat the couple or family by preventing, to the extent possible, a conflict of interest to arise where an individual's interests may not be consistent with the interests of the couple or the family being treated. If you feel it necessary to talk about matters that you do not wish to have disclosed, you should consult with a separate instructor or therapist who can treat you individually.

Extraordinary Events:

8. In the case that I become disabled, die, or am away on an extended leave of absence (hereinafter "extraordinary event,") the following Mental Health Professional Designee will have access to my client files. If I am unable to contact you prior to the extraordinary event occurring, the Mental Health Professional Designee will contact you. Please let me know if you are not comfortable with the below listed Mental Health Professional Designee and we will discuss possible alternatives at this time.

Tara Hedman, Registered Psychotherapist

4297 Austin Bluffs Pkwy, Suite #204

Colorado Springs, CO 80918

Telephone: 719-235-5325

The purpose of the Mental Health Professional Designee is to continue your care and treatment with the least amount of disruption as possible. You are not required to use the Mental Health Professional Designee for therapy services, but the Mental Health Professional Designee can offer you referrals and transfer your client record, if requested.

Electronic Records:

9. Hedman Counseling, PC/Rachael Fromkin may keep and store client information electronically on Hedman Counseling, PC/Rachael Fromkin's laptop or desktop computers, and/or some mobile devices. In order to maintain security and protect this information, Hedman Counseling, PC/Rachael Fromkin may employ the use of firewalls, antivirus software, changing passwords regularly, and encryption methods to protect computers and/or mobile devices from unauthorized access. Hedman Counseling, PC/Rachael Fromkin may also remotely wipe out data on mobile devices if the mobile device is lost, stolen, or damaged.

Hedman Counseling, PC/Rachael Fromkin may use electronic backup systems such as external hard drives, thumb drives, or similar methods.  If such backup methods are used, reasonable precautions will be taken to ensure the security of this equipment and they will be locked up for storage.  Hedman Counseling, PC/Rachael Fromkin uses a cloud-based service for storing or backing up information.  The cloud-based backup system Hedman Counseling, PC/Rachael Fromkin uses is Counsol.com and the email service provider Hedman Counseling, PC/Rachael Fromkin uses is Counsol.com. Hedman Counseling, PC/Rachael Fromkin may maintain the security of the electronically stored information through encryption and passwords. In addition, in order to maintain security of the electronically stored information Hedman Counseling, PC/Rachael Fromkin has employed the following security measures:

Entered into a HIPAA Business Associates Agreement with the cloud-based Hedman Counseling, PC/Rachael Fromkin and email service provider. Because of this Agreement, the cloud-based Hedman Counseling, PC/Rachael Fromkin and email service provider are obligated by federal law to protect the electronically stored information from unauthorized use or disclosure.

The computers that store the electronically stored information are kept in secure data centers, where various security measures are used to maintain the protection of the computers from physical access by unauthorized persons.

The cloud-based Hedman Counseling, PC/Rachael Fromkin and email service provider employ various security measures to maintain the protection of these backups from unauthorized use or disclosure.

It may be necessary for other individuals to have access to the electronically stored information, such as the cloud-based Hedman Counseling, PC/Rachael Fromkin or email service provider's workforce members, in order to maintain the system itself. Federal law protecting the electronically stored information extends to these workforce members. If you have any questions about the security measures Hedman Counseling, PC/Rachael Fromkin employs, please ask.

10.  I acknowledge that communications with my yoga/dance instructor (e.g. emails, chats, or video sessions) via Hedman Counseling, PC/Rachael Fromkin's client portal are encrypted and that emails sent from or to personal email accounts are not secure. I acknowledge and agree that all communication of a clinical nature should be sent through the Hedman Counseling Center client portal. A reasonable attempt will be made by my yoga/dance instructor to read and respond to the emails received via that site within business 72 hours. I understand that my yoga/dance instructor will not respond to personal and clinical concerns via regular email or texting. Email should not be used in the event of crisis or emergency. As a rule, personal and clinical communications (i.e. communication for purposes other than scheduling) should be reserved for scheduled session times (in-person sessions, video sessions, email sessions, or phone sessions) except in cases of emergency.  I further acknowledge that if either I or my yoga/dance instructor uses a cell phone that the conversation may not be secure and therefore not confidential. Although my yoga/dance instructor has taken substantial steps to ensure the confidentiality and privacy of therapy provided online, Hedman Counseling, PC/Rachael Fromkin cannot guarantee the security of any internet or cell phone transmissions or communications. I agree to take full responsibility for the security of any communication or treatment documentation on my own computer and in my physical location. If my yoga/dance instructor believes I am a danger to, or may become a danger to, yourself or anyone else, my yoga/dance instructor may inform others or insist that I be evaluated, in person, by another health care professional.

AS A CLIENT:

You as a Client agree and understand the following:

1. I understand that Hedman Counseling, PC/Rachael Fromkin may contact me to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to me in accordance with Hedman Counseling, PC/Rachael Fromkin's Consent for Communication of Protected Health Information by Unsecure Transmissions.

2. I understand that if I initiate communication via electronic means that I have not specifically consented to in Hedman Counseling, PC/Rachael Fromkin's Consent for Communication of Protected Health Information by Unsecure Transmissions, I will need to amend the consent form so that my therapist may communicate with me via this method.

3. I understand that there may be times when my yoga/dance instructor may need to consult with a colleague or another professional, such as an attorney or supervisor, about issues raised by me in session. My confidentiality is still protected during consultation by my yoga/dance instructor and the professional consulted. Only the minimum amount of information necessary to consult will be disclosed. Signing this disclosure statement gives my yoga/dance instructor permission to consult as needed to provide professional services to me as a client. I understand that I will need to sign a separate Authorization for Release of Information for any discussion or disclosure of my protected health information to another professional besides a colleague, supervisor or attorney retained by my yoga/dance instructor.

4. I understand that, in general, Hedman Counseling, PC/Rachael Fromkin does not provide Teletherapy, such as therapy over telephone or video chat. I understand that communications via email and text should be limited to administrative purposes and not used as an avenue for therapy or instruction. I understand that should I want Teletherapy, I will discuss my request with my yoga/dance instructor. I understand that it is in my yoga/dance instructor's sole discretion whether to accommodate my request for Teletherapy.  Should my yoga/dance instructor and I determine that Teletherapy is an appropriate option for my treatment, I understand that I will be required to sign a separate teletherapy disclosure statement.

If client or yoga/dance instructor is unable to attend in-office appointment due to inclement weather or other unforeseen circumstances, when feasible session may take place by phone or secure video chat at the previously agreed upon time. Payment cancellation policies remain in effect. Please discuss this option with your yoga/dance instructor in advance if you wish to utilize this option.

5. I understand that my yoga/dance instructor, does not accept personal Facebook, LinkedIn, Twitter, Instagram, and/or other friend/connection/follow requests via any Social Media. Any such request will be denied in order to maintain professional boundaries. I understand that Hedman Counseling, PC/Rachael Fromkin has, or may have, a business social media account page. I understand that there is no requirement that I "like" or "follow" this page. I understand that should I "like" or choose to "follow" Hedman Counseling, PC/Rachael Fromkin's business social media page that others will see my name associated with "liking" or "following" that page. I understand that this applies to any comments that I post on Hedman Counseling, PC/Rachael Fromkin's page/wall as well. I understand that any comments I post regarding therapeutic work between my yoga/dance instructor and I will be deleted as soon as possible. I agree that I will refrain from discussing, commenting, and/or asking therapeutic questions via any social media platform. I agree that if I have a therapeutic comment and/or question that I will contact my yoga/dance instructor through the mode I consented to and not through social media.

6. I understand that Hedman Counseling, PC/Rachael Fromkin uses testimonials in its marketing efforts. I understand that I will never be asked to provide a testimonial and I am not required or expected to provide one. If I wish to provide a testimonial regarding my experience with Hedman Counseling, PC/Rachael Fromkin, I may put the information in writing and provide it to my yoga/dance instructor, along with my signature and the following statement: "It is my intent to provide Hedman Counseling, PC/Rachael Fromkin with a testimonial to be used in its marketing efforts. I offer this of my own volition and have not been solicited to provide this testimonial. I understand that it may be possible for others to identify me based on the information I provide." No client names will be disclosed in testimonials.

7. I understand that if I have any questions regarding social media, review websites, or search engines in connection to my therapeutic relationship, I will immediately contact my yoga/dance instructor and address those questions.

8. I understand my yoga/dance instructor provides non-emergency therapeutic services by scheduled appointment only. If, for any reason, I am unable to contact my yoga/dance instructor by the telephone number provided to me, 719-235-5325, and I am having a true emergency, I will call 911, check myself into the nearest hospital emergency room, call Pikes Peak Mental Health Crisis Line at 719-635-7000, Colorado's Crisis Hotline (844) 493-8255 or the National Suicide Prevention Lifeline at 1-800-273-TALK(8255).  Hedman Counseling, PC/Rachael Fromkin does not provide after-hours service without an appointment.  If I must seek after-hours treatment from any counseling agency or center, I understand that I will be solely responsible for any fees due. I understand that if I leave a voicemail for my yoga/dance instructor on the phone number provided, my yoga/dance instructor will return my call by the end of the next business day, excluding holidays and weekends.

9.  If my yoga/dance instructor believes my therapeutic issues are above their level of competence, or outside of their scope of practice, my yoga/dance instructor is legally required to refer, terminate, or consult.   

10. I understand that I am legally responsible for payment for my yoga/dance instructor services. If for any reason, my insurance Hedman Counseling, PC/Rachael Fromkin, HMO, third-party payer, etc. does not compensate my yoga/dance instructor, I understand that I remain solely responsible for payment. I also understand that signing this form gives permission to my yoga/dance instructor to communicate with my insurance Hedman Counseling, PC/Rachael Fromkin, HMO, third-party payer, collections agency or anyone connected to my yoga/dance instructor funding source regarding payment. I understand that my insurance Hedman Counseling, PC/Rachael Fromkin may request information from my yoga/dance instructor about the therapy services I received which may include but is not limited to: a diagnosis or service code, description of services or symptoms, treatment plans/summary, and in some cases my yoga/dance instructor's entire client file. I understand that once my insurance Hedman Counseling, PC/Rachael Fromkin receives the information I or my yoga/dance instructor has no control of the security measures the insurance Hedman Counseling, PC/Rachael Fromkin takes or whether the insurance Hedman Counseling, PC/Rachael Fromkin shares the required information. I understand that I may request from my yoga/dance instructor a copy of any report Hedman Counseling, PC/Rachael Fromkin submits to my insurance Hedman Counseling, PC/Rachael Fromkin on my behalf.  Failure to pay will be a cause for termination of therapy services.

11.  I understand that this form is compliant with HIPAA regulations and no medical or therapeutic information or other information related to my privacy, will be released without permission unless mandated by Colorado law as described in this form and the Notice of Privacy Policies and Practices. By signing this form, I agree and acknowledge I have received a copy of the Notice or declined a copy at this time. I understand that I may request a copy of the Notice at any time.

12. As a client, you may request a copy of your Client Record at any time. In accordance with the Rules and Regulations of the State Board of Registered Psychotherapists, I will maintain your client record (consisting of disclosure statement, contact information, reasons for yoga/dance instruction, notes, etc.) for a period of seven (7) years after the termination of services or the date of our last contact, whichever is later. I cannot guarantee a copy of your Client Record will exist after this seven-year period.

13. I understand that if I have any questions about my yoga/dance instructor's methods, techniques, or duration of services, fee structure, or would like additional information, I may ask at any time during the yoga/dance instructor process. By signing this disclosure statement I also give permission for the inclusion of my partners, spouses, significant others, parents, legal guardians, or other family members in therapy when deemed necessary by myself or my yoga/dance instructor. I agree that these parties will have to sign a separate Consent for Third-Party Participation Agreement or may have to sign a separate disclosure statement in order to participate in yoga/dance instruction.

14. I understand that should I choose to discontinue yoga/dance services for more than sixty (60) days by not communicating with Hedman Counseling, PC/Rachael Fromkin or my therapist, my treatment will be considered "terminated." I may be able to resume yoga/dance instruction after the sixty (60) day period by discussing my decision to resume therapy services with Hedman Counseling, PC/Rachael Fromkin. Ability to resume services after sixty (60) days will depend upon my instructor's availability and will be within their sole discretion. This disclosure statement will remain in effect should I resume services if one (1) year has not elapsed since my last session. However, I may be asked to provide additional information to update my client record. I understand "discontinuing services" means that I have not had a session with my instructor for at least sixty (60) days, unless otherwise agreed to in writing.

15. There is no guarantee that yoga/dance instruction will yield positive or intended results. Although every effort will be made to provide a positive and healing experience, every therapeutic experience is unique and varies from person to person. Results achieved in a therapeutic relationship with one person are not a guarantee of similar results with all clients.

16. I understand that my instructor may refer me to and/or expect me to avail myself of outside supportive resources, including, but not limited to, other health care professionals, as deemed appropriate. A failure on my part to comply with such recommendations may result in termination of the therapeutic relationship. I understand that my instructor will discuss this with me prior to terminating the therapeutic relationship for this reason. It is acknowledged that online or distance yoga/dance instruction is not a substitute for medication given under the care of a psychiatrist or doctor. I understand and agree that Rachael Fromkin is neither a psychiatrist nor a doctor and is therefore not legally allowed to prescribe medications or to give medical advice. It is further understood that online or distance counseling is not appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts.

17. Because of the nature of yoga/dance services, I understand that my therapeutic relationship has to be different from most other relationships.  In order to protect the integrity of the wellness process the therapeutic relationship must remain solely that of instructor and client. This means that my instructor cannot be my friend, cannot have any type of business relationship with me other than the therapeutic relationship (i.e. cannot hire me, lend to or borrow from me; or trade or barter for services in exchange for yoga/dance services); cannot have any kind of romantic or sexual relationship with a former or current client, or any other people close to a client, and cannot hold the role of yoga/dance instructor to their relatives, friends, the relatives of friends, people known socially, or business contacts.

18. I understand that should I cancel within 24 hours of my appointment or fail to show up for my scheduled appointment without notice ("no-show"), excluding emergency situations, my instructor has a right to charge my credit card on file, or my account, for the full amount of my session.

19. I also affirm, by signing this form, I am at least fifteen (15) years old and consent to treatment and therapy services here at Hedman Counseling, PC/Rachael Fromkin or that I am the legal guardian and/or custodial parent with the legal right to consent to treatment for any minor child/ren who is under the age of fifteen (15), for whom I am requesting therapy services here at Hedman Counseling, PC/Rachael Fromkin.

20. I understand that if I am consenting to treatment and therapy services for my minor child/ren that my instructor will request that I produce the Court Order Custody Agreement and/or Parenting Plan that grants me the authority to consent to mental health services for my minor child. Further, I understand and agree to keep my instructor informed of any proceedings or supplemental court orders that affect my parenting rights, custody arrangements, and decision-making authority. I understand that failing to provide the Court Order Custody Agreement and/or Parenting Plan will prohibit my therapist from providing therapy to my minor child/ren. I understand that it is beyond the scope of my instructor's practice to provide custody recommendations. Any request for custody recommendations will be denied. A Court is able to appoint professionals with the expertise to make such recommendations.

21. By signing this form, I affirm that I am fully informed of the services I am requesting and that Hedman Counseling, PC/Rachael Fromkin is providing, and grant my consent to receive such services.  

My signature below affirms that the preceding information has been provided to me in writing by my primary instructor, or if I am unable to read or have no written language, an oral explanation accompanied the written copy. I understand my rights as a client/patient and should I have any questions, I will ask my instructor.