Therapy Consent for Messages

Valerie Andersen, PSYD

Licensed Psychologist || PY9730

Consent For Messages
Name
Date of Birth

MonthDayYear
Date
Age
Phone number
Email Address
example@example.com
Do you give Dr. Valerie Andersen, PSYD. permission to leave messages for you regarding appointment scheduling and other issues related to therapy?

YesNo
If yes, how would you prefer to receive messages?

EmailVoicemailText messageMessage left with someone else
If you prefer a message be left with someone else, please provide their:
Name:
Relationship to client
If you consent to the above, which numbers or email addresses would you prefer?
Cell phone
Work / Other (please specify)
Email
Signature

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Date

MonthDayYear
Date
Dr. Valerie Andersen, PSYD. Licensed Psychologist | #PY9730 | 10300 49th Street North, Clearwater, FL 33762 | 321.368.9646
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