Consent to Collect Personal Health Information

At Mindfulness with Mae, we collect your Personal Health Information during the therapeutic process to help determine the types of treatment that are most appropriate for you.

Personal Health Informaiton may include:

Your name, address and phone number
Your physical and mental health
Your personal health history
Issues that you are experiencing

Name

First NameLast Name

Date of Birth

Email

example@example.com

Have you ever participated in psychotherapy before?

What current challenges are you facing?

Do you have a history of suicide or suicidal ideation?

YesNo

If yes, when was the last attempt?

1-3 months ago3-6 months ago6-12 months agoOver 1 year ago

Is there anything else you believe we should know?

I, First Name Last Name understand the potential risks associated with participating in psychotherapy and agree to take part in private, individual session(s).

Signature

Date