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CLIENT SAFETY AGREEMENT

Melissa Parenteau, MA, LPC Hill Country LPC
Psychotherapist Fredericksburg, Tx 78624
512-762-6841

Please read the following statements and sign below to signify that you have received this information and agree to comply with the statements. Please initial next to each statement.

I agree to keep myself safe, by not hurting myself accidentally or on purpose. I agree not to commit suicide and/or homicide by my own hand or by action taken in response to my behavior by others, including the police.

If I am in crisis and believe that I am a danger to myself or to others, I agree to telephone the MHMR Crisis Line at 472-4357 (472-HELP), to call 911 or go to the nearest hospital emergency room and allow them to treat me.

I understand that my therapist is available by telephone at 512-762-6841 during normal working hours, 9:00 AM until 5:00 PM Monday through Friday. If you leave a message it will be returned the same day, although it may be in the evening.

I understand that I may be seen by my therapist during scheduled appointments only. No walk-in psychotherapy appointments are available.

I understand a copy of this agreement will be kept in my chart and that I will be given a copy upon request.

I understand that if I violate this contract, I may be referred to another mental health professional or facility.

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Signed by Melissa Parenteau M.A., LPC
Signed On: October 12, 2023

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October 12, 2023 10:15 am CDT

CLIENT SAFETY AGREEMENT Uploaded by Melissa Parenteau M.A., LPC - melissa@hillcountrylpc.com IP 151.213.182.188