Skip to content

Call Dr. Heidi Cherwony 561-699-4639

Mind and Body Doctor
  • Home
  • About
  • Therapy
  • Testing
  • Forms
  • News
  • Events
  • Contact
  • Home
  • About
  • Therapy
  • Testing
  • Forms
  • News
  • Events
  • Contact
Mind and Body Doctor
  • Home
  • About
  • Therapy
  • Testing
  • Forms
  • News
  • Events
  • Contact
  • Home
  • About
  • Therapy
  • Testing
  • Forms
  • News
  • Events
  • Contact
Book appointment

Consent for Services

  1. Home
  2. Consent for Services
Thank you for completing the form. I look forward to seeing you soon.
1
0%
https://mindandbodydoctor.com/wp-content/plugins/nex-forms-lite
false
message
https://mindandbodydoctor.com/wp-admin/admin-ajax.php
https://mindandbodydoctor.com/consent-for-services
yes
This form is to document that I give my permission and consent to Dr. Heidi Cherwony, to provide psychotherapeutic treatment and/or psychological assessment to me and/or my child.
–Select–
–Select–
I agree that these services are mutually understood to be appropriate, and that I may withdraw my consent at any time.
I agree that these services are mutually understood to be appropriate, and that I may withdraw my consent at any time.
Provider of services accepts assignment.
–Select–
–Select–
I understand that once an appointment is scheduled, I will be expected to pay for it unless I provide 24 hours advanced notice of cancellation for therapy sessions and 48 hours advanced notice of cancellation for testing sessions. Only exceptions are those agreed to by both parties.
I understand that once an appointment is scheduled, I will be expected to pay for it unless I provide 24 hours advanced notice of cancellation for therapy sessions and 48 hours advanced notice of cancellation for testing sessions. Only exceptions are those agreed to by both parties.
–Select–
–Select–
I understand that conversations with Dr. Cherwony will be confidential. However, I understand that all psychologists, by law, must report actual or suspected child or elder abuse, neglect or domestic violence to the appropriate authorities. In addition, all psychologists have a legal responsibility to protect anyone who may be threatened with violence, harmful or dangerous acts (including those to myself) and may break confidentiality of our communication if such a situation arises. I understand that Dr. Cherwony will make reasonable efforts to resolve these situations before breaking confidentiality.
I understand that conversations with Dr. Cherwony will be confidential. However, I understand that all psychologists, by law, must report actual or suspected child or elder abuse, neglect or domestic violence to the appropriate authorities. In addition, all psychologists have a legal responsibility to protect anyone who may be threatened with violence, harmful or dangerous acts (including those to myself) and may break confidentiality of our communication if such a situation arises. I understand that Dr. Cherwony will make reasonable efforts to resolve these situations before breaking confidentiality.
–Select–
–Select–
I understand that an evaluation is not a guarantee of any desired outcome.
I understand that an evaluation is not a guarantee of any desired outcome.
–Select–
–Select–
I understand that I am financially responsible for this treatment/ assessment.
I understand that I am financially responsible for this treatment/ assessment.
–Select–
–Select–
I understand that my signature below will act as a signature on file. My signature indicates that I have read this consent and agree to its terms.
I understand that my signature below will act as a signature on file. My signature indicates that I have read this consent and agree to its terms.
Mind and Body Doctor

Office Locations

2200 NW Corporate Blvd, Suite 311
Boca Raton, FL 33431

10800 N. Military Trail, Suite 213
Palm Beach Gardens, FL 33410

Phone

(561) 699-4639

E-mail

drheidic@gmail.com

Facebook
  • Home
  • About
  • Therapy
  • Testing
  • Forms
  • News
  • Events
  • Contact

©2021 Mind and Body Doctor.  All Rights Reserved | Site Designed by Dorron Designs.