Disclosure Statement

Karen Collins, MSW, LCSW Therapy Practice

Therapy With Karen Collins

Dandelion Media, LLC

www.RLOVESTORY.com

561-512-9743

Disclosure Statement

Thank you for choosing my therapy services. As a Licensed Clinical Social Worker (LCSW) in the State of Florida and the State of Tennessee and a Licensed Independent Social Worker (LISW) in the State of Ohio, I abide by all associated licensure rules and regulations.

As My Client, You have the following rights:

To expect that a licensee has met the minimal qualifications of training and experience required by law;
To examine public records maintained by the Board and to have the Board confirm credentials of a licensee;
To report complaints to the Board;
To be informed of the cost of professional services prior to receiving the services;
To be assured privacy and confidentiality while receiving services as defined by rule and law, including the following exceptions: 1) Reporting suspected child abuse; 2) Reporting imminent danger to clients or others; 3) Reporting information required in court proceedings or by Client's insurance company, or other relevant agency; 4) Providing information concerning licensee case consultation or supervision; 5)Defending claims by client against licensee.
To be free from discrimination because of age, color, culture, disability, ethnicity, national origin, gender, race, religion, sexual orientation, marital status or socioeconomic status.

My Fees:

Therapy Services can be paid prior to or at the time of session by cash, check, credit card or debit card for your convenience. If you are unable to keep an appointment, kindly notify me of cancellation within 48 hours of the appointment. If appointment is not cancelled within 48 hours of appointment time, the full session fee will be charged to your credit or debit card on file. Please note that all services and fees are shared on my Services Offered page on my website at www.RLoveStory.com.

If you feel that I have violated your rights at any time, you can file a complaint with the Florida HealthCare Complaint Portal at https://www.flhealthcomplaint.com or by calling 1-800-245-7339. In Ohio, the complaint portal can be found at https://elicense.ohio.gov/oh_filecomplaint

If you should have any questions or concerns, please do not hesitate to ask me. My goal is to always provide a positive therapy experience.

In addition, I consent to SMS and electronic communications to include scheduling appointments, appointment reminders and other commincations that may be associated with treatment as indicated below.

____ Email Only

____ SMS Text Message Only

____ Email and Text

____ No SMS or Electronic Communication

I (We) have Read this disclosure statement and understand the content. I also acknowledge receiving a copy of this statement that includes the fees for the services provided and I accept and agree to the cost of the therapy sessions and policies regarding payments.

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Client Signature Date

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Client Signature Date