THIS IS TO VERIFY THAT I AM AWARE THAT I AM RECEIVING THERAPY SERVICES FROM TONYA WILLIS, WHO IS A LICENSED PROFESSIONAL COUNSELOR ASSOCIATE. TONYA HAS RECEIVED HER MASTER’S DEGREE IN EDUCATIONAL COUNSELING SHE HAS COMPLETED HER STATE LICENSURE EXAM AND IS WORKING ON HER COUNSELING HOURS UNDER SUPERVISION FOR FULL LICENSURE. I EXPECT THIS THERAPIST TO BE SUPERVISED WEEKLY BY A FULLY LICENSED THERAPIST AND THAT THEY WILL MEET WEEKLY TO DISCUSS MY CASE.
I AM AWARE THAT I MAY CONTACT THE SUPERVISING THERAPIST AT THEIR D.I.D NUMBER TO DISCUSS ANY CONCERNS I MAY HAVE REGARDING THE SERVICES I AM RECEIVING. I MAY EXPECT A RETURN CALL FORM THE SUPERVISOR WITHIN 24 HOURS.
I HAVE SIGNED A CONSENT AND DISCLOSURE AUTHORIZATION ALLOWING MY SESSION THERAPIST AND SUPERVISING THERAPIST TO DISCUSS MY CASE IN DEPTH. THIS FORM ACTS AS A RELEASE OF INFORMATION AND WILL BE IN EFFECT UNTIL MY RELATIONSHIP WITH MY SESSION THERAPIST IS TERMINATED.
I HAVE RECEIVED INFORMATION ON REPORTING TO THE BOARD ANY MISCONDUCT OR MALPRACTICE ISSUES I PERCEIVE NEED TO BE ADDRESSED. I DO AGREE TO DISCUSS THESE ISSUES WITH THE SUPERVISING THERAPIST TO SEE IF MY PROBLEM CAN BE RESOLVED AS WELL.
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