BRETT MOSER departure survey Your Name(Required) First Last Your Email(Required) Your Phone(Required)Disclosure Regarding Brett Moser's Departure and Attestation(Required) I attest that I am aware that Brett Moser will be leaving Change, Inc., and his last day will be on 9/27/24.Statement of Intent(Required)I would like to continue seeing Brett outside Change, lnc.I would like to discontinue seeing Brett.Desire Regarding A New Therapist(Required)I intend to continue in counseling -- I would like a FREE SESSION with another Change, Inc. therapist!I'm not sure about continuing in counseling -- I would a FREE SESSION with Change, Inc.'s transition/triage team to help me decide whether to continue and with whom!I intend to continue in counseling -- I would like to be referred to another therapist outside Change, Inc.I do not need a referral to another therapist.Disclosure and Consent Regarding Discontinuing Counseling Services with Change, Inc. and Transferring to Brett Moser(Required) I attest that I am aware that after 9/25/24, I will no longer be receiving counseling services from Change, Inc., and therefore will be discharged from their treatment environment. I understand that I may return to their treatment environment in the future, should I desire to do so and my treatment needs be compatible with their environment. I understand that Brett Moser will become responsible for my treatment in its entirety henceforth and do hereby release Change, Inc. from any and all responsibility for my care effective 9/26/24.Disclosure and Consent Regarding Discontinuing Counseling Services with Change, Inc.(Required) I attest that I am aware that after my last session with Brett Moser, I will no longer be receiving counseling services from Change, Inc., and therefore will be discharged from their treatment environment. I understand that I may return to their treatment environment in the future, should I desire to do so and my treatment needs be compatible with their environment. I do currently hereby release Change, Inc. from any and all responsibility for my care.Request to be Contacted Regarding Referral/Transition(Required) I request that Change, Inc. contact me via email/phone in line with my Statement of Intent Regarding Counseling // Desire Regarding Referral statement above.CAPTCHA Δ
