Forms & Referrals

Name *

First Name

Last Name

If client is 17 years old or younger (or an adult unable to give consent), please list child's/client's first and last name

First Name

Last Name

Phone *

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Checkbox *

By clicking on "Yes, I consent to telemental health services," I certify that I have read the "Consent to Participate in a Telemedicine Appointment" form or had this form read and/or had this form explained to me, that I fully understand its contents including the risks and benefits of the procedure(s), and that I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

Yes, I Consent to Telemental Health Services