Dr. Victoria Fleming
Your intake paperwork isn't complete until you've (1) retrieved intake forms from North Shore Counseling (click here) and uploaded them using the "Upload Intake Paperwork" button below, and (2) completed the on-line form contained on this page.
Thank you for your interest in counseling services! Please be aware that completing this form is simply the first step in the intake process. You are not formally under contract and we do not have a therapeutic relationship until after we have our first session together.
PLEASE READ THE CONTENT ON THIS PAGE CAREFULLY AND THEN COMPLETE THE FORM BELOW.
Distance Counseling Consent Form
This Agreement and Consent Form for Distance Counseling conducted by Dr. Victoria Manion Fleming is being provided to you (client) in order to inform you about Distance Counseling and answer frequently asked questions.
I (the Client undersigned) understand that I must be at least 18 years of age to consent. As a client of Dr. Victoria Manion Fleming, I declare that Dr. Victoria Manion Fleming may be legally required to disclose confidential information to make appropriate legal notifications if she or her agents or representatives reasonably believe I am involved in child or elderly abuse or neglect or if I intend to harm myself or another identifiable person.
Distance Counseling Options & Client Privacy
I (the Client) understand that Dr. Victoria Manion Fleming or her respective staff currently offer distance counseling via phone and visual telecommunication. She offers the following telecommunication options: Phone (land line or mobile), Skype, and FaceTime. I fully understand that no form of distance counseling guarantees client confidentiality. I understand that she can offer distance counseling via phone sessions and that telephone is not HIPPA protected. I understand that I will be charged a pre-arranged fee for services according to Dr. Victoria Manion Fleming’s fee schedule. I recognize that the process of Distance Counseling differs from in person counseling in that the full range of senses may not be readily expressible through electronic means. Dr. Victoria Manion Fleming does not guarantee resolution of any kind or assure success for online counseling, either explicit or implied. In addition, as a client of Dr. Victoria Manion Fleming, I can end services at any time, for any reason, without prior notification or explanation. Although Dr. Victoria Manion Fleming has taken significant steps to ensure the confidentiality and privacy of Online/ Distance communication, these actions, in whole or in part, cannot be 100% guaranteed due to the nature of internet and long-distant transmissions. I permanently agree to release and indemnify Dr. Victoria Manion Fleming from all suits, claims, and other actions originating from services provided through Distance Counseling.
Confidentiality and Distance Counseling
Clients are responsible for the confidentiality of their own environment and accept the limitations of confidentiality and privacy inherent to distance counseling, including but not limited to the following points for consideration:
I understand that Distance Counseling is generally provided utilizing technology and that there may be problems with technology (e.g. Internet connectivity), which is the fault of neither Dr. Victoria Manion Fleming nor the client. Internet availability may be limited or disrupted by things such as server maintenance, upgrades, or other problems (such as software or hardware malfunction) or natural or man-made disasters (such as terrorist acts, Internet viruses, and so forth). These types of problems are beyond the control of Dr. Victoria Manion Fleming and the client. If something like this were to occur, scheduled appointments would be re-scheduled. I, the client, understand that in the event of a technology failure during a phone or visual telecommunication session, immediate steps will be taken by the therapist to reconnect. Contact via email/text is the first backup step to failed phone and visual telecommunication reconnection. The therapist will repeatedly attempt to use these methods to contact me through the remaining session time (and I will do the same, as well). I, the client, will confirm receipt of successful contact. The compromised appointment will be rescheduled and, unless other arrangements are made, will be billed at the full rate.
I understand that in the event of an emotional emergency, and I cannot reach the counselors, I can either call 911 or local emergency response team or go to the nearest emergency room.
Recording of Sessions
I understand that no recording of sessions by me or by Dr. Victoria Manion Fleming is allowed, and neither Dr. Victoria Manion Fleming nor her representatives will record my visual or phone sessions, unless there is an explicit written consent by me for reasons that clearly benefit my treatment. I understand I am not to record session without the expressed written consent by Dr. Fleming.
Distance Counseling Using Visual Telecommunication
By completing the form below, I am acknowledging that I have read and understand the content on this page.