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920 West Chester Pike 1489 Baltimore Pike 709 E. Gay Street Havertown, PA 19083 Bldg. 200, Suite 250 West Chester, PA 19380 Springfield, PA 19064 Telephone: 610-544-2110 Fax: 610-604-9510 Confidentiality Statement In an effort to create and maintain the most productive therapeutic experience for your child, please consider two concerns. First, it is important for your child to feel comfortable in knowing that the content of their therapy sessions will remain confidential unless there is an imminent danger to that child or another person. Second, in order to allow your child to feel that all concerns can be safely discussed, it is necessary for your child's therapist to remain neutral and uninvolved in any parental custody determinations. Please note that Associates of Springfield Psychological does not provide custody evaluation services. If you wish to obtain a custody evaluation, you may ask your therapist for a referral. Your signature below indicates your agreement with treatment conditions explained above. I (print names) ______________________________/______________________________ agree that I will not seek treatment records nor request Associates of Springfield Psychological's participation in any custody determination proceedings regarding my child ______________________________ (child's name). (Signature)______________________________ Date:______________________________ (Signature)______________________________ Date:______________________________
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