| Telephone Sessions |

| Licensed Psychotherapist SW8380 * Board Certified Clinical Sexologist * Certified Sex Therapist |
| Leader in the Field of Sexuality and Counseling for Individuals, Couples and Families |
| Dr. Rothenberg |
| Orlando/Winter Park Florida Office 407-797-5468 DrRothenberg@aol.com |
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| Michael Ian Rothenberg, Ph.D., LCSW (disclosure page) I certify that: 1. I am over 18 years of age. 2. I am not and have not been told that I need to be under the care of a physician for a major mental or emotional illness. 3. I am not receiving individual counseling or psychotherapy with another practitioner. 4. I am not at present feeling suicidal or homicidal. 5. I accept full responsibility for informing Dr. Rothenberg immediately if I believe I am becoming seriously depressed, or I am having thoughts of injuring myself or another person. I understand that Dr. Rothenberg may contact local emergency services if he feels that my state of mind poses a danger to myself or to others. I understand that: 1.The records and notes from my communications will be kept confidential except where Dr. Rothenberg is legally required to release them. 2. My personal information will be kept confidential. If I decide to use a different e-mail provider, I need to inform Dr. Rothenberg in advance. 3. Dr. Rothenberg will make every effort to return e-mails within 48 hours of receipt. 4. I am responsible for payment in advance for all services. 5. Email consultation and telephone consultation are not considered counseling or therapy but serve to provide educational or informational support. 6. Sessions with Dr. Rothenberg are reserved exclusively for you. All sessions not cancelled 24 hours before scheduled appointment time will be billed at full session rate. 7. I have read all the information listed here in the disclosure page and by participating in telephone sessions, I report understanding and I agree to all of the above. |
| Michael Ian Rothenberg Ph.D., LCSW 1950 Lee Road Suite 101 Winter Park, FL 32789 CounselingAndSexualHealth.com 407-797-5468 |
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