Privacy and Consent Statement
I do hereby acknowledge, understand and consent to the following conditions
of coaching, counseling or therapy with Earl Ledford, MSW, LCSW, CST by my
email, chat, video or phone sessions for myself.
services offered at e-sextherapy.com are limited to adults. By soliciting
and accepting any e-sextherapy.com services or productsyou certify that you are an
The coaching I receive will be conducted by Earl
Ledford, MSW, LCSW, CST who is a licensed clinical social worker and
certified sex therapist in Florida.
understand that this service will use coaching techniques
intended to assist me in growing as an individual, as a partner within a
relationship, and/or as a member of a family or social group.
understand that Earl Ledford, MSW, LCSW, CST is not a physician and
cannot, therefore, prescribe or recommend medication.
understand that upon request of assistance with a sexual concern,
recognized procedures for the correction of sex dysfunction
will also be used. When
clinically appropriate and with my consent, this treatment may utilize the
use of educational audiovisual materials of sexually explicit nature,
recommendations for reading, behavioral "homework" tasks, and
other awareness and/or relaxation assignments.
understand that in during my sessions, no nudity, no real-time therapist
directed self-examinations, nor any overt sexual behavior will be involved
in the solving of my sexual concerns.
Further, understand that I will not be expected to engage in any
sexual activities at home that are against my moral convictions and I
maintain the right to ask about the therapeutic purpose of any homework
assignment given to me.
understood that Earl Ledford, MSW, LCSW, CST is a "consultant"
and a resource professional only, and that the interventions and
recommendations offered may be freely accepted or rejected.
Therefore, decisions made during and after sessions and/or
treatment are the responsibility of myself, myself and my partner, myself
and my spouse, and/or my family.
and behavior inventories may be administered as deemed necessary.
I will be informed of the purpose of the assessments/inventories
and will be apprised of any costs involved, if any.
test findings and disclosures during the sessions will be held in strict
confidence with protection of state laws, but also subject to them.
I understand that the privacy and confidentiality of conducting
sessions via email, chat, video, and telephone sessions will be vulnerable
to other users of those services. The
level of confidentiality and privacy can not be assured at the same high
level as in a in office face-to-face session.
I acknowledge that the telephone session will provide more privacy
and confidentiality than email, chat and video session.
I also acknowledge that the video sessions will provide more
information for Ear Ledford to provide consultation for my sexual concerns
but may be more open to compromises of privacy and confidentiality.
I further understand that any requests for obtaining medical or
mental health information from others or releasing such information to
others will be done only with my written consent.
Agreement to this form does not give permission to release or
obtain information. I have
the ability to withdraw this consent and agreement at anytime, recognizing
I can undo any action or breeches due to the vulnerability of
communicating on the internet or telephone that take place before my
following exceptions to these policies:
• I will release specific information about you or your account
to comply with any valid legal process such as a search warrant, subpoena, statute or court order.
• I will also release specific information if there is an
attempted breach of the security of the e-sextherapy.com site or a physical threat to you or others.
have been informed of the fee and payment arrangements.
Payment for all sessions are to be made before session appointments
are confirmed and, under no circumstances, later than one hour before my
scheduled appointment. No
session will be conducted before verification of full payment made by
myself. I further understand
that my insurance will most likely not help me pay for email, chat, video
conferencing and phone session fee payments and that the contract is
between myself and the insurance company, and it is they who determine
whether or not they are going to pay and to what extent.
I agree to assume all responsibility for the appropriate fees for
the sessions arranged and conducted through www.e-sextherapy.com with Earl
Ledford, MSW, LCSW, CST.
understand that I can terminate my agreement for services with Earl
Ledford, MSW, LCSW, CST at anytime, but that I may be financially
responsible for the fees for a scheduled session not cancelled at least 24
hours before the scheduled session.
understand I may
find advertising or other contents on this site that link to the sites and
services of e-sextherapy.com partners, suppliers, advertisers and other
third parties. In many cases, the links represent cooperative projects or
are mutual links established with persons or entities connected with the
e-mail addresses and other identifying information are not sold, rented,
or otherwise shared with any other organization, group, individual, or
entity unless you have opted-in to receive third party promotional
communications. The e-sextherapy.com website contains links to other
websites and it is recommend that you review their respective privacy
policies if you elect to connect to them.
may contact Earl Ledford at any time with questions regarding the consent,
him at email@example.com