Contact — Tanza Haskins Counseling Services

Notice of Privacy Practices Receipt and Acknowledgement of Notice Form

Please click here to read the Notice of Privacy Practices document before submitting the form.

Please read terms of use before submitting the form.

Notice of Privacy Practices Receipt and Acknowledgement of Notice

Client Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Email

Name of Client/Guardian or Personal Representative (signature)

I hereby acknowledge that I have received and have been given an opportunity to read a copy of Tanza Haskins Counseling Services, Inc. Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I may contact Tanza Haskins, LCSW at 919-839-0042.

Today's Date

MM

DD

YYYY

Client/Guardian confirms receipt:

Yes

No

Therapist's Name (print)

Client Information Form

Please read terms of use before submitting the form.

Telehealth Consent Form

Please click here to read the Telehealth Guide before submitting the form.

Please read terms of use before submitting the form.

Telehealth Consent Form

Consent For Telehealth Consultation

1. I understand that my Therapist wishes me to engage in a telehealth consultation. 2. My Therapist explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider. 3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing. 4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. 5. I have had a direct conversation with my Therapist during which I had the opportunity to ask questions in regard to this session. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE

Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge: 1. Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call my Therapist. 2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services. 3. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care. 4. I do not assume that my Therapist has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my Therapist to have any of this information in the Telehealth by SimplePractice Service. 5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me • That I fully understand its contents including the risks and benefits of the procedure(s). • That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

Email

Client/Guardian Name (signature)

Today's Date

MM

DD

YYYY

Good Faith Estimate Notice

Please click here to read the Good Faith Estimate Notice

Patient Opt-Out Information

Please click here to read the North Carolina Health Information Exchange Authority Patient Opt-Out Information

Contact Tanza

E: tanza@tanzahaskinscounselingservices.com

P: 919.839.0042

F: 919.301.8818

Six Forks Office Center

8410 Six Forks Road, Suite 102

Raleigh, NC 27615

Notice of Privacy Practices Receipt and Acknowledgement of Notice Form

Client Information Form

Telehealth Consent Form

Good Faith Estimate Notice

Patient Opt-Out Information

Contact Tanza

Questions before getting started?

FAQ’s

Hours

Notice of Privacy Practices Receipt and Acknowledgement of Notice Form

Client Information Form

Telehealth Consent Form

Good Faith Estimate Notice

Patient Opt-Out Information

Contact Tanza

Questions before getting started?

FAQ’s

1. What can I expect during my first therapy session?

2. How long is a therapy session?

3. How frequently will I meet for therapy?

4. What is telehealth?

5. How is my privacy protected?

6. How much does therapy cost?

7. How do I pay for therapy?

8. What is the cancellation policy?

9. How do I communicate with Tanza?

10. After-hours coverage?

Hours