Mobile Mental Health Clinic Informed Consent and Practice Policies
Please use one form per participant- The next virtual Mobile Mental Health Clinic is scheduled for 01/30/2021 @ 12 pm. Completing this form will register you for a session at that event.
Your Name
*
First Name
Last Name
Name of minor client
First Name
Last Name
Client date of birth
*
-
Month
-
Day
Year
Date
Mobile Phone Number (in case we need to help you log into your session)
-
Area Code
Phone Number
Email
*
example@example.com
What type of session are you interested in?
Individual
Group
Music Therapy
Informed Consent to Treatment + Practice Policies
Date
*
-
Month
-
Day
Year
Date
Signature (Guardian if client is a minor)
*
Submit
Should be Empty: