Carolyn's Informed Consent

Please REVIEW the below document prior to continuing.

COVID-19 Liability Waiver
Signature

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I agree to ALL of the above COVID-19 Liability Waiver statements (please initial)
Date

Month Day Year
Date
Printed Name of Client

INFORMED CONSENT
Initial to accept ALL above conditions of this Informed Consent (Primary client)
Initial to accept ALL above conditions of this Informed Consent (Secondary client)
Signature of Primary Client

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Signature of Client/Parent #2

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Date

Month Day Year
Date

CREDIT CARD AUTHORIZATION FORM
Card Holder's Name (as it appears on credit card)
Street Address
Apt/Suite
City
State
Zip Code
Credit Card Type

Visa MasterCard Discover AMEX
Credit Card number
Exp. Date
CCV Code
Email
example@example.com
Cardholder's Signature

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CONSENT FORCOUNSELING SESSIONS via Doxy.me
Signature of Client

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Date

Month Day Year
Date
Printed Client Name
To complete your submission, please attach a VALID government issued photo ID. (Driver's license or Passport) *

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