• Consent Form

    All consents given below are valid for one year from the commencement of treatment and must be renewed annually. You have the right to rescind your consent to release your personal information at any time - please give written notice of your desire to do so.
  • Primary Care Physician

    Please fill in the below information for your primary care physician.
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  • Therapist

    Please fill in the below information for your therapist.
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  • Emergency Contact

    I give limited permission for disclosure to my emergency contact to be used only in case of life threatening emergency.
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  • Clear
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    Pick a Date
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