Client Signature Record - Martin Counseling
Acknowledgment: I have read and agree to the terms of "Notice of Privacy Practices" and "Consent for Services". I acknowledge that I am the client or the legal representative of the client, and I agree that the generated electronic signature is a legally binding equivalent to my handwritten signature.
Sign in to Google to save your progress. Learn more
Signed By: *
Name of the client (if different from Signature):
Date Signed: *
MM
/
DD
/
YYYY
Date of Birth of Client *
MM
/
DD
/
YYYY
Primary Phone number *
Primary Email Address
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms