Privacy Practices Receipt

Step 5

Client Name:

If signing for a minor, please provide full legal name of legal guardian

Date of Birth

Acceptance | Privacy Practices Receipt

I hereby acknowledge that I have received and been given an opportunity to read a copy of the Notice of Privacy Practices of Carrie T. Ishee. I understand if I have any questions regarding the Notice or my privacy rights, I can contact Carrie T. Ishee, M.A., LPCC, LPAT, ATR-BC, PCC, Privacy Officer.

You're done!

Thank you for filling out these forms. I’ll be in contact soon.