Receipt of Privacy Practices Notice
  1. I understand that I have been informed about the Privacy Practices Notice of Kardia® Counseling & Consulting, PLLC;
  2. I understand the Privacy Practices Notice discusses how my personal health care information may be used and/or disclosed, how it is stored, protected, sent, and disposed of, my rights with respect to disclosure of health care information, and how and where I may file a privacy-related complaint;
  3. I may review a copy of this Notice on the website at Patient Documents;
  4. I understand that the terms of this Notice may be changed in the future, and these changes will be posted in the waiting room of the office and/or posted on the website ( I may also request a copy of the new Notice by calling 910-725-2074.

Patient Signature:
Patient Signature Date:
Parent/Legally Responsible Person:

(if patient is below 18 years of age)
Parent Signature Date: