Acknowledgement of notifications.

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Agreement for Psychological Services

I understand that I have read Dr. Stiritz’s Agreement for Psychological Services and I understand and agree to comply with these policies. I understand that these policies are available to me on Dr. Stiritz’s website but that I may always request a hard copy if I am unable to access them.Today’s Date

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HIPAA Notice of Privacy Practices

I acknowledge that I have read the HIPAA Notice of Privacy Practices. I understand that the HIPAA Notice of Privacy Practices is available on Dr. Stiritz’s website but that I may always request a hard copy if I am unable to access it.Today’s Date

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Appointment Cancellation and Payment Policy

I understand that I will be charged for appointments not cancelled more than 24 hours in advance of my scheduled appointment. I understand that payment is due at the time of service, unless Dr. Stiritz and I have agreed to an alternate billing plan.Today’s Date

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