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Terms and Disclaimer for Appointment Request Form

Privacy Notice and Consent

By submitting this form, you acknowledge and agree to the following:

Protected Health Information (PHI)

The information you provide may constitute Protected Health Information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA). We are committed to protecting your privacy and maintaining the confidentiality of your health information in accordance with federal and state laws.

Information Collection and Use

• Information submitted through this form will be used solely for appointment scheduling and initial assessment purposes

• Your information may be accessed by authorized healthcare providers and administrative staff involved in your care

• We will not share your information with third parties without your written authorization, except as required by law

Security Measures

• This form is transmitted through encrypted, HIPAA-compliant technology

• Your information is stored on secure servers with restricted access

• We maintain physical, electronic, and procedural safeguards to protect your PHI

Your Rights

You have the right to:

• Request access to your health information

• Request amendments to your health information

• Request restrictions on how your information is used or disclosed

• File a complaint if you believe your privacy rights have been violated

Consent for Communication

By providing your contact information, you consent to receive appointment-related communications via the methods you specify (phone, email, or text). You may revoke this consent at any time.

Important Disclaimers

Emergency Situations

This form is NOT for emergency situations. If you are experiencing a mental health crisis, suicidal thoughts, or any psychiatric emergency, please:

• Call 911 immediately

• Go to your nearest emergency room

• Contact the National Suicide Prevention Lifeline at 988

• Call your local crisis intervention team

No Provider-Patient Relationship

Submitting this form does not establish a provider-patient relationship. A therapeutic relationship begins only after you have been accepted as a client and have attended your first appointment.

Response Time

While we strive to respond within one business day, this form should not be used for urgent matters requiring immediate attention. For urgent concerns, please call our office directly.

Technical Limitations

Although we use secure technology, no method of electronic transmission is 100% secure. By using this form, you acknowledge this inherent risk.

Age Requirements

If you are under 18 years of age, a parent or legal guardian must provide consent before we can schedule your appointment.

Contact Information

For questions about this privacy notice or to exercise your rights, please contact:
Office Phone: +1 (786) 247-1308
Email: equilibriummhs@gmail.com

By clicking “Submit” below, you acknowledge that you have read, understood, and agree to these terms and conditions.