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Disclaimer: Non-HIPAA Compliant Form

Please be advised that the form you are about to submit may not be fully compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). By using this form, you acknowledge and agree to the following:

Potential Risks: The information you provide through this form, which may include personal health information (PHI), may not be protected in accordance with HIPAA standards. There is a potential risk that your information could be accessed, used, or disclosed without authorization.

Use Caution: We strongly advise against submitting sensitive or confidential health information through this form. If you need to provide such information, please contact our office directly at info@trueyoutherapyandwellness.com to discuss secure alternatives.

No Guarantee of Privacy: While we strive to protect your privacy, we cannot guarantee the security and confidentiality of information submitted through this form.

Alternative Methods: For a more secure method of communication, please consider contacting us by phone, mail, or in person.

By clicking "Submit" and providing your information, you acknowledge that you understand the potential risks and limitations of using this form and consent to proceed.

If you have any questions or concerns, please contact us anytime at info@trueyoutherapyandwellness.com or Monday-Friday, 9am-5pm at (503) 610-6452.