HIPAA & Privacy Practice Notice & Consent

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Disclosures

Email *

Today's Date *

YYYY

I understand that I am about to acknowledge my patient rights were read fully and understood. *

Yes

FULL LEGAL NAME *

MAILING ADDRESS *

PHONE NUMBER *

EMAIL ADDRESS *

1. REASON FOR REQUESTING SERVICES *

2. I WAS REFERRED BY *

3. I give permission for my information to be released to the Indiana Department of Child Services or my Probation Officer, and I understand I can take permission away at any time for any reason by contacting the agency. I understand if I do not release this information, I am responsible for the cost of my own fees as well as providing all updates in my case.
*

Yes

No, I will pay for my own services and update Indiana Department of Child Services on my own.

Required

4. I understand the following information will be released: *

Assessments/Diagnoses/Reason for Treatment, Reports/Notes, Case Completion

Required

4. I also give permission for information about my progress in services to be released to the following parties (if applicable):

5. I UNDERSTAND I AM ABOUT TO CONSENT FOR SERVICES TO BE SET UP ONLINE OR BY PHONE. *

YES

Required

SIGNATURE (TYPE NAME HERE) *

On this day, *

YYYY

Clear form

Never submit passwords through Google Forms.

This form was created inside of Rose Project Consulting, LLC. Report Abuse

Forms