Disclaimer for Therapy Services Your Name(Required) First Last Consent(Required) By checking this box, I consent to the Disclaimer for Therapy Services below.I understand that Denise O’Doherty LPC MSN, is a Licensed Marriage and Family Therapist, a Licensed Professional Counselor, and a Registered Nurse. She has provided psychotherapy in private practice for over 30 years and has 30+ years of experience in her profession. I also understand that Denise is Licensed in the State of Texas to do “in person”, (face to face) as well as teletherapy (via the internet) counseling, and she is certified to do therapy via teletherapy in the State of Florida. I realize that I am requesting consultation from Ms. ODoherty and am living in a state where she is not licensed to practice psychotherapy. As a result, she is not able to provide psychotherapy, give me any documentation of any such therapy and I will not be eligible for reimbursement from my insurance company. Knowing this I am still voluntarily requesting consultation from Ms. O’Doherty.Date MM slash DD slash YYYY Signature(Required)