HavenPoint Health Intake and Consent Form

HavenPoint Health Intake and Consent Form
Step 1: Your Information
Today's Date

MonthDayYear
Date
Respondent Type
Patient's First Name
Patient's Last Name
Patient's Date of Birth

MonthDayYear
Date
Gender
Marital Status
Number of Children
Local Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Step 2: Communication
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
May we leave a message on Home Phone?
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
May we leave a message on Cell Phone?
Email Address
example@example.com
May we contact you by email?
How did you hear about our services?
Email Notifications Preferences

Other
Text Message (SMS) Preferences

Other
Step 3: Consent to Services
Consent for Collection of Personal Health Information
Acknowledgment
Signature for Collection of Personal Health Information
Date of Signature

MonthDayYear
Date
Consent for Release of Information
Acknowledgment
Signature for Release of Information
Date of Signature

MonthDayYear
Date
Acknowledgment of Use of Electronic Communication and Video/Virtual Therapy Policies
Acknowledgment
Final Signature
Final Signature Date

MonthDayYear
Date
Should be Empty: