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I acknowledge that this practice may use and disclose my protected health information (PHI) for treatment, payment, and healthcare operations in accordance with HIPAA.

I understand that submitting this form does not establish a provider–patient relationship

until services are formally initiated. Services may include psychiatric evaluation,

medication management, and/or psychotherapy as clinically appropriate.

For minor patients, I certify that I am the parent or legal guardian and authorize care.

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