Date of Birth
Trans Female (MTF or Male to Female)
Trans Male (FTM or Female to Male)
Gender Non-Conforming (i.e. not exclusively male or female)
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Street Address Line 2
State / Province
Postal / Zip Code
Who is this referral for?
Why are you seeking mental health services? (select all that apply)
What is your preferred method for therapy?
No preference (first available)
How did you learn about BRAVE?
Signature of the Individual or Guardian (typed name)
I agree that this agreement may be electronically signed. I agree that the electronic signature appearing on this agreement is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility. I understand that •I am not required to sign this consent and that if I refuse to sign this consent my treatment, payment, or eligibility for benefits will not be affected. I may also request a copy of this consent after I sign it. •This consent form expires in seven (7) years. I have the right to revoke this consent at any time by writing to the Agency, except to the extent that the agency has acted in reliance on it. Past information I previously consented to release will not be retrieved from agencies that received that information. I understand that my revocation must be in writing. •The Agency has posted a Notice of Privacy Practices, and I may request a paper copy of the Notice from the Agency. I acknowledge that I have been given an opportunity to read and/or request a copy of the Notice and that I have read the Notice. The Notice describes ways in which my personal information may be used and disclosed within and outside of the Agency. Its terms may change and I may obtain a copy of the Notice by writing to: CCIN SERVICEPOINT c/o Flagler Health+ Care Connect, 400 Health park, Blvd. St. Augustine, FL 32086. •I understand that neither the Agency, nor the CCIN, can control how another Participant will use or disclose my information that it receives under this consent. It is possible that the other agency will disclose my information to others, and that the disclosed information may no longer be protected by federal privacy regulations.
Should be Empty: