Signature Sheet
Review the consent statements, then sign and date in Sections 1 and 2 (and Section 3 if applicable).
Client Name
*
Full Name
Birthdate
*
-
Month
-
Day
Year
Consent Acknowledgement
I have received the Client Guide containing important written information including: Informed Consent, a Description of Therapy, Confidentiality Issues, Fee Information, Client Rights and Responsibilities, and my Notice of Privacy Practices.
Signature
*
Date
*
-
Month
-
Day
Year
Consent for Treatment
I hereby give my consent for treatment, which authorizes SpringHaven, Inc. to evaluate and/or treat myself for counseling. Treatment means provision, coordination, or management of clinical/counseling care and related services by one or more providers.
Signature
*
Date
*
-
Month
-
Day
Year
For Insurance and Special Billing Clients
I consent to allow SpringHaven, Inc. to use or disclose my protected health information to any and/or all the following that may apply to me: Insurance Company, Employee Assistance Program, Amish Church Fund, Church Partnership Program and Non-profit Ministries for payment purposes. Payment means the activities undertaken by SpringHaven, Inc. to obtain reimbursement for the provision of counseling services. I authorize any of the above to make payment directly to SpringHaven, Inc. for services rendered.
Signature
Date
-
Month
-
Day
Year
Sign and Submit
Sign and Submit
Should be Empty: