TERMS & CONDITIONS

Please read these terms and conditions which apply to the provision of my professional services. By making an appointment, you are agreeing to the following terms and conditions. If you are unable or unwilling to agree to these terms and conditions, then you should not book an appointment or continue with your course of therapy.

CONFIDENTIALITY

By signing this form, I consent that Uesila Sousa, may release information to a specific individual or agency if it has been determined that a vulnerable person (child or elder) is at risk; if I, as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested.

I have accurately and truthfully answered any questions and provided background information during the initial consultation and /or first therapy session and will continue to do so during any subsequent therapy sessions.

Please Note: You can print, sign and send in an email to ------------------------------ or simply request a copy upon booking. 

Print Name.............................................................................................. 

Signed Name............................................................................................ 

Date...................................................................................................... 

Thank you for your understanding and cooperation. If you have any further questions, please contact me.