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I authorize Arohi Counseling
Authorization to disclose or obtain confidential client information
By Signing This Form, I Understand The Following
Due To The New Federal Patient Confidentiality Laws (Hipaa)
Acknowledgment Of Our Notice Of Privacy Practices
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Contact Us
Home
About Us
Training
Training for Therapists
Leadership Development Program
Resources
Forms
Registration Form
I authorize Arohi Counseling
Authorization to disclose or obtain confidential client information
By Signing This Form, I Understand The Following
Due To The New Federal Patient Confidentiality Laws (Hipaa)
Acknowledgment Of Our Notice Of Privacy Practices
Reviews
Contact Us
(610) 457-7640
I hereby acknowledge that I have received or have been given the opportunity to receive a copy of Arohi Counseling, LLC Notice of Privacy Practices.
By signing below:
I am “only” giving acknowledgment that I have received or have had the opportunity to receive the Notice of our Privacy Practices.
Patient Name (Type or Print)
Patient’s Date of Birth
Date
Signature of Patient or Parent/Legal Guardian
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