Client Testimonial Consent Form

Client Testimonial Consent Form

Form time: 5 min
HottoID
FormLinker
Name of the person providing responses to these questions.

First Name - Person providing responses to these questionsLast Name - Person providing responses to these questions
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you a...
What challenges were you facing before connecting with HōttoCare?
How did HōttoCare help you?
What would you say to another caregiver who feels overwhelmed?
What has changed in your life because of the support you received?
Upload a photo you'd like us to consider using.

Cancelof
How may we identify you?
May we use your... (select all that apply.)
Final Acknowledgement

I understand that:
- My participation is voluntary.
- My decision will not affect any services I receive from HōttoCare.
- I may revoke my authorization in writing at any time, although information already published may not be removable.
- My story may be edited for grammar or length while preserving its meaning.
By submitting this form, I acknowledge that I have read and agree to the HōttoCare Testimonial & HIPAA Authorization.
Signature
Date of signature

MonthDayYear
Date
SourceEnv
Should be Empty: