Therapy On Demand (914) 490-3798 services@therapyondemand.org Confidential, Convenient, and Cost-Effective An alternative to face-to-face therapy Questions? We have free initial consultations!

Home Page Benefits of Telephonic Therapy Professional Services About Paul Mission Statement and Objectives Pricing and Payment Appointments Contact Information Crisis – Help Lines Helpful Links Have any questions about how Telephonic Therapy works? We have FREE INITIAL CONSULTATIONS!

Initial Client Information Request For Treatment Form: In order to facilitate effective client treatment please complete this form and submit prior to first scheduled appointment. If you have any questions please feel free to contact therapyondemand.org by telephone or email. Personal Information: First name Last name Date of birth Sex Male Female Address: City:  State: Zip Code: Phone:  Email: Marital status: Divorced Single Married Employed: Yes No Reason(s) for seeking services: Appointment duration: one hour - $80.00 half hour - $45.00 1st choice appointment: Date:  -- mm/dd/yy Time:  -- hh:mm:ss am/pm 2nd choice appointment: Date:  -- mm/dd/yy Time:  -- hh:mm:ss am/pm 3rd choice appointment: Date:  -- mm/dd/yy Time:  -- hh:mm:ss am/pm Preferred method of contact: Email Phone I accept the below terms: Yes No Disclaimer THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. WHO WILL FOLLOW THIS NOTICE: This notice describes our offices practices and that of: Any health care professional authorized to enter information into your chart. All employees, staff and other personnel. OUR PLEDGE REGARDING MEDICAL INFORMATION: We understand that medical information about you and your health is personal we are committed to protecting medical information about you. We create a record of the care and services you receive at our offices or otherwise brought to our attention. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the office personnel. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. Law to requires us: 1. Make sure the medical information that identifies you is kept private; 2. Give you this notice of our legal duties and privacy practices with respect to medical information about you; and 3. Follow the terms of the notice that is currently in effect. HOW WE MAY DISCLOSE MEDICAL INFORMATION ABOUT YOU. The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed; however, all of the ways we are permitted to use and disclose information will fall within one of the categories: For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, or other individuals who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes Information about you to people outside the office who may be involved in your medical care such as family members. For Payment: We may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. For Health Care Operations: We may use and disclose medical information about you for office operations. These uses and disclosures are necessary to run the office and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many patients to decide what additional services the office should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, and other personnel for review and learning purposes. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are. D. Appointment Reminders. We may use and disclose medical Information to contact you as a reminder that you have an appointment for treatment or medical care at the office. Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternative that may be of interest to you. Health-Related Benefits and Services: We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you. Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care, As Required By Law: We will disclose medical information about you when required to do so by federal, state or local law. To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat, SPECIAL SITUATIONS. Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. Workers' Compensation: We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related Injuries or illness. Public Health Risks: We may disclose medical information about you for public health activities. These activities generally include the following; o To prevent or control disease, injury or disability; o To report births and deaths; o To report child abuse or neglect; o To report reactions to medications or problems with products; Effective Date 4/14/03 I understand that the specific type of information to be obtained and/or released includes case summary, tests, progress notes, and/or telephone communication, and that the purpose or need of this information exchange is continuity in treatment. I understand that the information obtained and/or released is from records whose confidentiality is protected by state and/or federal law. The medical record information to be obtained and/or released may contain information pertaining to family, medical, psychiatric, HIV/AIDS, drug and/or alcohol history, diagnosis and treatment. I also understand that this consent is revocable except to the extent that action has been taken in reliance thereon, and that this consent will remain in force for a reasonable time, not to exceed one year 2004 therapyondemand.org. All Rights Reserved. DISCLAIMER: Information and/or advice obtained through therapyondemand.org are for informative purposes only, and should not be interpreted as a substitute for clinical mental health evaluation or treatment for specific medical or psychological conditions or disorders. It is definitely not intended to provide or confirm a diagnosis, nor is any claim made as to the effectiveness of any treatment or product. You should seek prompt medical care and/or advice of a licensed practitioner for any specific physical or mental health problem. Users of this web site are advised to exercise due diligence and common sense in selecting an appropriate practitioner, product or service. therapyondemand.org shall have no liability whatsoever for direct or indirect, special or consequential damages relating in any way to the use of information provided by therapyondemand.org. Use of this online service is subject to this disclaimer's terms and conditions. You must be 18 years of age or older to use this service. TREATMENT AUTHORIZATION AND PAYMENT POLICY: I authorize you to give me reasonable and proper clinical care by today's standards. I hereby agree to pay T.C.S. The full and entire amount of any and all charges or bills for services rendered to the above named patient by T.C.S. Should I fail to do so I agree to pay any costs and expenses incurred in collecting such charges, including court fees and attorney's fees, as well as interest at the maximum rate permitted by law from the date(s) of service until date payment is received by T.C.S. Furthermore, if I must cancel or change an appointment, I will notify T.C.S. At least one day in advance. (24 hours advance notice. Or else I recognize that I will be billed, and agree to pay, for the reserved time. I also acknowledge receipt of, and understanding of, the Notice of Privacy Practices effective April 14, 2003.