LEE FOX MARLEY, LCSW
15303 Texas Street
Austin, Texas  78734
Ph (512) 913-1984
Fax (888) 242-2823

NOTICE OF PRIVACY PRACTICE
RECEIPT AND ACKNOWLEDGEMENT OF NOTICE

NAME:___________________________________________________________

DATE OF BIRTH:__________________________________________________

SOCIAL SECURITY NUMBER:_________________________________________

I acknowledge that I have received and have been given an opportunity to read a copy of Lee Fox Marley, LCSW, Notice of Privacy Practice.


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Signature of Client                                         Date


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Signature of Parent, Guardian, or Personal Representative   Date


I hereby acknowledge that I consent to the Privacy Practice Policy of Lee Fox Marley, LCSW.  I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Lee Fox Marley, LCSW, and/or contact the Secretary of the Department of Health and Human Services at: 200 Independence Avenue, S.W. Washington, DC 20201 or by calling (202) 619-0257.


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Signature of Client                                         Date


_____________Client refuses to acknowledge consent


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Signature of Psychotherapist                                Date