Marsha Rand, PLLC - Secure Client Area

Client Information

Legal First Name / Middle Initial

Last Name

Preferred First Name ( optional )

Date of Birth ( Must be at least 18 years old )
( MM-DD-YYYY )

Pronouns ( optional )

Gender Identity ( optional )

Street Address

Street Address 2

City

State

ZIP Code

How did you find me?

Cell Phone ( for Text Message Reminders )
Preferred Contact #

Home Phone
Preferred Contact #

Bill To Contact

Same as above Different

First Name or Organization Name / Middle Initial

Last Name

Street Address

Street Address 2

City

State

ZIP Code

Phone

Log in Details

Confirm Email

Username
Between 8 and 40 letters and numbers

Local Time / Timezone

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )

Question #1

Answer

Question #2

Answer

( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

Terms for Treatment

You will find a full explanation of terms related to entering therapy explained on the Disclosure and Consent to Treatment form. Please read that form carefully. Below are basic terms regarding confidentiality and payment for services.

Confidentiality: Your confidentiality is very important to us. Within limits of the law, information revealed by you during therapy is kept strictly confidential and will not be revealed to any other agency or person without your written permission. When a couple is involved in therapy, we view the couple as the client. Therefore releases of information for couple sessions require the written approval of both individuals.

Mandatory Reporting: In accordance with state laws, there are certain situations in which I am required to reveal information obtained during therapy to other persons or agencies without your permission. I am not required to inform you of my actions in this regard. These situations are as follows: (a) if you threaten harm to yourself or others; (b) if you reveal information regarding abuse or neglect of a child or a dependent adult. In any of these situations, I am required to report this information to the appropriate local authorities.

Payment: Fee for service is due at the scheduled appointment. I understand that, if I cannot attend a scheduled session, I am to give a 24 hour notice. If I do not give this notice, I agree to pay the full session fee.