(650) 367-7797

Acknowledgment of Notifications

Please print out and sign this notification form and return to me at our next meeting.


 

I acknowledge the receipt of Office Policies and Agreement for Psychotherapy Services and understand and agree to comply with them.

_________________________________________               _____________
Signature                                                                    Date

_________________________________________               _____________
Nicholas H. Ney, Ph.D.                                              Date

 

I also acknowledge the receipt of the HIPAA Notice of Privacy Practice for my review.

_________________________________________               _____________
Signature                                                                     Date

 

Nicholas Ney, Ph.D
499 Seaport Court, Suite 201
Redwood City, CA 94063
Tel/fax: 650.367.7797