Office Policies - Dr. D. Janell Dietz
Please print this form, fill it out, and send it to Dr. D. Janell Dietz when scheduling your first appointment.
The following office policies apply to all therapeutic work done by Dr. D. Janell Dietz. Agreement to enter into
therapy with Dr. D. Janell Dietz implies that you have read, and accept, all office policies below. We apologize for
asking you to read the 'legal fine print', but professionalism and our standard of ethics require that all office
policies be understood before therapy begins.
Dr. D. Janell Dietz is located in the United States, in the state of Nevada. Dr. D. Janell Dietz is licensed by the
state of Nevada. You therefore agree, as our client, that any Psychotherapy or Counseling performed at a
distance (such as over the telephone) by Dr. D. Janell Dietz will be considered to take place within the state of
Nevada, regardless of your location as a client, and will be governed by the laws and ethical requirements of the
state of Nevada. Since Nevada has legal and ethical standards that are among the highest in the United States,
this both protects our clients and creates a uniform standard for our therapy sessions.
Confidentiality is a mandated requirement for all therapeutic sessions. Nevada therapists are required to
maintain strict confidentiality of all information disclosed in your session, and not reveal any information from
your sessions without your consent in writing, except where otherwise required by law. Those situations would
include the following:
• If the therapist determines you are a serious danger to yourself or others, or 'gravely disabled', i.e. unable
to care for yourself, the therapist is required to break confidentiality to protect you, or protect others from you.
• If you disclose child or elder abuse, the therapist is required by law to report this to the appropriate
authorities.
• If the therapist's records are subpoenaed by a court of law, or the therapist is otherwise ordered by the
courts to break confidentiality, the therapist is required to obey the law.
All fees, whether paid by credit card, check or money order, must be paid and cleared in advance. Sessions will
not take place until payment has been cleared and approved, avoiding bank fees and collection charges.
Scheduled appointments are time set aside for you. It is requested that any cancellations or schedule changes
be made 48 hours in advance. A minimum notice of 24 hours is required for all changes. Any cancellations or
changes made with less than 24 hour notice will be charged in full. You agree that you will be responsible for
payment for any session not cancelled at least 24 hours in advance, and will pay Dr. D. Janell Dietz for all such
scheduled sessions, even if you cancel later (with less than 24 hours notice), or are otherwise unavailable to
participate in the session.
Your therapist, Dr. D. Janell Dietz, is committed to giving you the highest standards of professional care. If, for
any reason, your therapist believes that she is unable to continue to be effective in working with you, the
therapist will make every effort to find an appropriate referral for you. Due to the nature of therapy over a
distance, you understand that this might not always be possible.
You acknowledge that by scheduling a therapy session with Dr. D. Janell Dietz, you understand and agree to all
of the office policies above.
----------------------------------------------------------------------------------------------------
I (we) have read the above office policies, understand them, and agree to them in full.
__________________________________(____)__________-_____________
Print Client Name Phone
____________________________________________
Client Signature
____________________________________________________________
Address City/State
_____________________________________
Print Additional Client Name (for couples counseling)
_____________________________________
Additional Client Signature
To schedule sessions with Dr. D. Janell Dietz, please print this form, fill out, initial at the bottom of each page,
and sign the client signature line. Mail to Dr. D. Janell Dietz at the following address: P.O. Box Las Vegas,
NV 89081
Please print this form, fill it out, and send it to Dr. D. Janell Dietz when scheduling your first appointment.
The following office policies apply to all therapeutic work done by Dr. D. Janell Dietz. Agreement to enter into
therapy with Dr. D. Janell Dietz implies that you have read, and accept, all office policies below. We apologize for
asking you to read the 'legal fine print', but professionalism and our standard of ethics require that all office
policies be understood before therapy begins.
Dr. D. Janell Dietz is located in the United States, in the state of Nevada. Dr. D. Janell Dietz is licensed by the
state of Nevada. You therefore agree, as our client, that any Psychotherapy or Counseling performed at a
distance (such as over the telephone) by Dr. D. Janell Dietz will be considered to take place within the state of
Nevada, regardless of your location as a client, and will be governed by the laws and ethical requirements of the
state of Nevada. Since Nevada has legal and ethical standards that are among the highest in the United States,
this both protects our clients and creates a uniform standard for our therapy sessions.
Confidentiality is a mandated requirement for all therapeutic sessions. Nevada therapists are required to
maintain strict confidentiality of all information disclosed in your session, and not reveal any information from
your sessions without your consent in writing, except where otherwise required by law. Those situations would
include the following:
• If the therapist determines you are a serious danger to yourself or others, or 'gravely disabled', i.e. unable
to care for yourself, the therapist is required to break confidentiality to protect you, or protect others from you.
• If you disclose child or elder abuse, the therapist is required by law to report this to the appropriate
authorities.
• If the therapist's records are subpoenaed by a court of law, or the therapist is otherwise ordered by the
courts to break confidentiality, the therapist is required to obey the law.
All fees, whether paid by credit card, check or money order, must be paid and cleared in advance. Sessions will
not take place until payment has been cleared and approved, avoiding bank fees and collection charges.
Scheduled appointments are time set aside for you. It is requested that any cancellations or schedule changes
be made 48 hours in advance. A minimum notice of 24 hours is required for all changes. Any cancellations or
changes made with less than 24 hour notice will be charged in full. You agree that you will be responsible for
payment for any session not cancelled at least 24 hours in advance, and will pay Dr. D. Janell Dietz for all such
scheduled sessions, even if you cancel later (with less than 24 hours notice), or are otherwise unavailable to
participate in the session.
Your therapist, Dr. D. Janell Dietz, is committed to giving you the highest standards of professional care. If, for
any reason, your therapist believes that she is unable to continue to be effective in working with you, the
therapist will make every effort to find an appropriate referral for you. Due to the nature of therapy over a
distance, you understand that this might not always be possible.
You acknowledge that by scheduling a therapy session with Dr. D. Janell Dietz, you understand and agree to all
of the office policies above.
----------------------------------------------------------------------------------------------------
I (we) have read the above office policies, understand them, and agree to them in full.
__________________________________(____)__________-_____________
Print Client Name Phone
____________________________________________
Client Signature
____________________________________________________________
Address City/State
_____________________________________
Print Additional Client Name (for couples counseling)
_____________________________________
Additional Client Signature
To schedule sessions with Dr. D. Janell Dietz, please print this form, fill out, initial at the bottom of each page,
and sign the client signature line. Mail to Dr. D. Janell Dietz at the following address: P.O. Box Las Vegas,
NV 89081
Office Policies
 |
 |
 |
 |
 |
 | |  | |  | |  | |  | |  | |  | |  |