GOOD LIFE POSITIVE PSYCHOLOGY

Acknowledgement of Notice of Privacy Practices

This form is provided to acknowledge your receipt of the Notice of Privacy Practices from GOOD LIFE POSITIVE PSYCHOLOGY. The Notice of Privacy Practices provides information about how GOOD LIFE POSITIVE PSYCHOLOGY may use and disclose your protected health information. We encourage you to review it carefully. The Notice of Privacy Practices is subject to change. If the Notice is changed, we will notify you and you may obtain a revised copy by visiting our website at www.good4life.org or request a paper copy from our staff.

By signing below, I acknowledge receipt of the Notice of Privacy Practices from GOOD LIFE POSITIVE PSYCHOLOGY.

Signature: ________________________ (Client / Parent / Guardian)

Signature: ________________________ (Client / Parent / Guardian)

Signature: ________________________ (Child/Adolescent 14 Years +)

Signature: ________________________ (Witness)

OFFICE USE ONLY

Date: ____________

Date: ____________

Date: ____________

Date: ________________

I attempted to obtain the patients signature in acknowledgement of this Notice of Privacy Practices but was unable to do so as documented below.

Date: Initials: Reason: