Safe Journey Counseling PLLC

10149 N 92 Street Suite 103-C

Scottsdale, AZ 85258
Phone: 480-250-1857
Fax: 480-361-8307
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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVATE PRACTICE

I,

acknowledge that I have received the following

documents regarding private practice in psychotherapy.

1) . HIPPA compliance information.
2) . Office policy and procedures.
3) . Clients Rights in psychotherapy.
Clients Name:
Clients Signature:

Date:

It is your right to refuse to sign this document.

FOR OFFICE USE ONLY

The reason that a standard acknowledgement (such as the above) of the receipt of the notice of
privacy practices was not obtained:
Client refused to sign
Communication barriers prohibited obtaining the acknowledgement.
An emergency situation prevented this office from obtaining it.
Others: