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Informed consent agreement 

 

Welcome to Change, Inc.!

This legally binding document provides information about counseling and psychotherapy services you are about to receive. Please review carefully, and feel free to ask any questions. You are encouraged to return to this form at any time during your treatment process with us to re-familiarize yourself with our policies. If you've already filled it out once, there is no need to fill it out a second time.

Instructions

Read each statement, and check the box next to it to "agree" with it.
EMERGENCY DISCLAIMER(Required)
COVID-19/OTHER PUBLIC HEALTH CRISES PROVISIONS & EXPECTATIONS(Required)
LEAST RESTRICTIVE THERAPEUTIC SETTING DISCLAIMER(Required)
ABOUT OUR SERVICES(Required)
DIVERSITY & INCLUSION(Required)
BIO/PSYCHO/SOCIOCULTURAL/SPIRITUAL PHILOSOPHY(Required)
WORK AGREEMENT(Required)
WORKING CREDIT/DEBIT CARD REQUIRED ON FILE(Required)
PAYMENT PROCESSING PROVISIONS(Required)
DECLINED CHARGES/PAST DUE BALANCES/COLLECTIONS(Required)
90-DAY EVALUATION PERIOD / WEEKLY OR BI-WEEKLY SESSIONS REQUIRED(Required)
ASSESSMENTS/STARTUP FEE(Required)
EXPECTED SESSION LENGTH / VARIABLE BETWEEN 50-60 MINUTES(Required)
CANCELATION/MISSED SESSIONS/INCLEMENT WEATHER & POWER OUTAGES(Required)
PARENT/FAMILY SESSIONS(Required)
TERMINATION OF SERVICES(Required)
CONFIDENTIALITY/PERSONAL HEALTH INFORMATION(Required)
MANAGED CARE-FREE STATUS/NON-COMMUNICATION WITH OUTSIDE ENTITIES EXCEPT WHERE REQUIRED BY LAW(Required)
HIPAA PRIVACY NOTICES(Required)
SOCIAL AND ELECTRONIC MEDIA INTERACTION(Required)
PERSONAL/PROPERTY INJURY WAIVER(Required)
RESOLUTION OF ADMINISTRATIVE/LOGISTICAL GRIEVANCES(Required)
OTHER CONFLICT RESOLUTION(Required)
LEGAL NOTIFICATIONS(Required)
CONTRACT GOVERNED BY LAW(Required)
BINDING EFFECT OF AGREEMENT(Required)
AFFIXING OF NAME AS DIGITAL SIGNATURE(Required)
Type full name.
Your Email(Required)
Address entered will receive a signed copy of this Informed Consent Agreement.
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