Consent to Telebehavioral Services
By signing this document, you are consenting to services with Nine Lives Counseling Service, as well as indicating you understand your privacy rights when you engage in services.
Email
First Name
Last Name
Phone Number
Address
Professional Disclosure Statement – Consent to Telebehavioral Services
By signing this document, I confirm that I have read the Explanation of Services document and agree to the terms outlined in that document. I agree to engage in counseling through a private, secure video conferencing platform (Zoom). I understand that my private information will be protected to the best of the agency’s ability, but that potential data leaks may occur. I will be notified immediately if there is reason to believe my private information has been obtained by someone without authorization. I reserve the right to revoke disclosure of my information or terminate services at any time.
Your Signature
Clear
Date
Submit
Powered by