I hereby authorize the treatment and support staff of SEYLA Counseling, Inc. to provide In-Home Counseling services and give permission to park on my property and enter my home where services will be provided.

    I attest that the service location is within 15 miles of 32940.

    I understand that my scheduled appointment time is approximate, and subject to road, traffic, and weather conditions. I will avail myself 15 minutes leeway before and after the scheduled time. I understand I will receive notification if the appointment is affected beyond those parameters.

    I understand, if I may elect an option whereby my Emergency Contact will be notified if I do not answer the door. I understand that a request for a welfare check may be submitted to the local police department if there is no immediate response from my emergency contact; however, staff are not required to do so.

    I understand if I am not at the scheduled In-Home Counseling location, a No Show fee will be assessed and charged to the credit card on file.

    I understand the staff of SEYLA Counseling, Inc., will not be responsible for house keys.

    I understand I will be required to provide the pass code for limited access locations.

    I understand it is my responsibility to secure pets during the session.

    I understand household members may participate during the session.

    I understand that my session may be overheard by others in the home. Disruptions may occur in the home that may affect the quality and flow of therapy and/or assessments/evaluations.

    I hereby authorize SEYLA Counseling, Inc. to record sessions conducted at the In-Home Counseling location. These audio and/or video recordings are used for quality assurance, excluded from clinical record, and not subject to release to anyone.

    I understand In-Home Counseling is not available during holidays and have the option of utilizing holiday service hours at the main office location.

    I understand that I may be liable for any damages to staff vehicle(s) while service is rendered at the In-Home Counseling location.

    I understand that SEYLA Counseling, inc., has made every reasonable effort to enable HIPAA compliant protocols and Secure Web Browsing from available vendors.

    I understand there are potential risks to the technology related to the Client Portal and other website features, including interruptions, unauthorized access, and technical difficulties.

    I understand that participation is voluntary and I may elect to terminate therapeutic services without penalty at any time.