Prior to meeting with a counselor, please print the following document and familiarize yourself with its contents. This document informs you concerning the nature of the therapeutic relationship, your rights and obligations, and your consent to receive treatment.

You are encouraged to keep the all pages but the final page for your records.

Once you have familiarized yourself with the contents, including any questions or clarifications you have sought from the service provider, you may print your name, sign and date the last page, and deliver it to LOTUS Counseling & Consulting, PLC in one of the following ways:

  • You may scan the complete last page and send it as an email attachment to lotusnwa@sdf.org. Please use the public encryption key found on this website to encrypt both the attachment and the email body.

*Download and import the public encryption key.

  • You may mail the complete last page using the US Postal Service; you are strongly encouraged to send the page Certified Mail in order to confirm receipt.

You have the right to assume all risks to your privacy and use an unrecommended method of delivery, including:

  • Scanning the completed document and sending it as an email attachment without encryption (high risk).
  • Scanning the completed document and sending it as an SMS+ text message attachment (high risk).
  • Taking a photograph of the completed document and sending this as an SMS+ photo (moderate electronic risk, high privacy risk).

Document Identification: ARLOT#IC-202007 (11pp)