top of page



The undersigned patient or responsible party (parent, legal guardian, or conservator) consents to and authorizes services by Richard M. Zeitner, Ph.D. These services may include psychotherapy and other appropriate alternative therapies.


The undersigned understands that he/she has the right to:


  1.  Be informed of and participate in the selection of treatment services.

  2.  Receive a copy of this consent.

  3.  Withdraw this consent at any time.



Your signature below serves as an acknowledgement that you have received the HIPAA Notice Form.

Thanks for submitting!

bottom of page