I request that payment of authorized insurance benefits be made on my behalf to Andrea T. Latell, LPC. I authorize any holder of medical information about me to release to the health care financing administration and its agents any information needed to determine these benefits. If I have a co-pay, I am required to make a payment at each visit. Clients must notify Andrea T. Latell when insurance has been switched to another carrier or discontinued.

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Each client will be treated with dignity and respect regardless of sex, age, race, handicap, or origin.

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Each client will be treated as an individual and therapy will be based on individual needs.

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Each client has a right to expect that all records and information learned will be kept confidential and only released by written permission of client or custodian if client is a minor or specifically required by law.

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Confidentiality may be broken in the event of eminent danger to self or others, a subpoena from court, or a suspected child abuse complaint as defined by law.

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Each client has the right to expect that he/she will be treated by a competent staff whom are free from mind altering, mood changing substances and function according to a professional code of ethics.

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Each client may expect appropriate referral to meet specific needs.

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I am aware that I may request a copy of Notice of Privacy Rights (NPP) copies by calling Andrea Latell at 804-435-7355 or stopping by 25 Office Park Drive Suite 2 Kilmarnock.

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I agree to receive telehealth services, if I choose that option.  Telehealth involves the delivery of mental health services including assessment,  diagnosis and treatment using interactive audio, video and data communications.  I understand that I will not be in the same room as my provider.  I understand that there could be technical difficulties and that I will not hold the provider liable.

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By typing my name in the box below, I am confirming that I have read all of the above statements as well as understand and agree. This serves as my electronic signature.

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Electronic signature: