| HIPAA GUIDELINES |
Informed Consent for Telephone & Online Consultation Email Session Services for Michael Ian Rothenberg, Ph.D., LCSW (disclosure page) I certify that: 1. I am over 18 years of age. 2. I am not and have not been told that I need to be under the care of a physician for a major mental or emotional illness. 3. I am not receiving individual counseling or psychotherapy with another practitioner. 4. I am not at present feeling suicidal or homicidal. 5. I accept full responsibility for informing Dr. Rothenberg immediately if I believe I am becoming seriously depressed, or I am having thoughts of injuring myself or another person. I understand that Dr. Rothenberg may contact local emergency services if he feels that my state of mind poses a danger to myself or to others. I understand that: 1.The records and notes from my communications will be kept confidential except where Dr. Rothenberg is legally required to release them. 2. My personal information will be kept confidential. If I decide to use a different e-mail provider, I need to inform Dr. Rothenberg in advance. 3. Dr. Rothenberg will make every effort to return e-mails within 48 hours of receipt. 4. I am responsible for payment in advance for all services. 5. Email consultation and telephone consultation are not considered counseling or therapy but serve to provide educational or informational support. 6. I have read all the information listed here in the disclosure page and by clicking the ‘I ACCEPT’ button below, I report understanding and I agree to all of the above. I ACCEPT I DECLINE |
| Licensed Psychotherapist SW8380 * Board Certified Clinical Sexologist * Certified Sex Therapist |
| Leader in the Field of Sexuality and Counseling for Individuals, Couples and Families |
| Dr. Rothenberg |
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| Orlando/Winter Park Florida Office 407-797-5468 DrRothenberg@aol.com |
| Michael Ian Rothenberg Ph.D., LCSW 1950 Lee Road Suite 101 Winter Park, FL 32789 OnlineSexualAddiction.com 407-797-5468 |
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