Informed Consent for Telephone & Online Consultation Email Session Services for
Dr. Anne Rothenberg, MH 14391 (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. Anne Rothenberg immediately if I believe I
am becoming seriously depressed, or I am having thoughts of injuring myself or another person. I
understand that Anne 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. Anne 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 Anne Rothenberg in
advance. 3. Dr. Anne 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
|Anne Rothenberg, Ph.D.
Licenced Mental Health Counselor MH14391
1950 Lee Road Suite 219 Winter Park, FL 32789
|Internationally Recognized Leader in the Field of Sexuality and
Counseling for Individuals, Couples and Families