ADULT CONTACT FORM
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Address
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Format: (000) 000-0000.
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Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Information
Primary Phone
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Format: (000) 000-0000.
Secondary Phone
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Format: (000) 000-0000.
Relationship to client
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Previous Psychotherapy
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Dates
Policies and Procedures: I was provided with the Child Development Associates “Policies and Procedures” document, and I was given the opportunity to read and ask questions about the content of the document, including the relevant sections on fees, payments and teletherapy. My signature below indicates my informed and willful consent to these policies, and to my treatment with CDA.
First Name
Last Name
Signature
Telehealth, E-mail, and SMS communication disclosure: It is important to be aware that electronic communications can be relatively easily accessed, and hence can compromise the privacy and confidentiality of such communication. I understand that the transmission of my medical information could be interrupted or distorted by technical failures, or accessed by unauthorized persons.
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2 digit month, 2 digit day, 4 digit year
Date
Signature
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6 Palmer Avenue | Scarsdale, NY 10583 | 914-723-2228
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