Client First Name *

Last Name *

Can the primary client independently sign legal documents? *

Client is considered a legal/independent adult and can sign independently.
Client is NOT considered a legal/independent adult and requries a guardian signature.

(If under 18 or not considered a legal/independent adult a Primary a Guardian is Required to Sign)

Parent/Guardian First Name *

Primary Guardian

Parent/Guardian Last Name *

Primary Guardian

Consent for Telehealth Therapy *

I Consent to Participating in counseling services with Choices in Counseling including Telehealth Therapy with Choices in Counseling.
I DO NOT Consent to Telehealth Therapy with Choices in Counseling.

Date/Time