Patient Telehealth Consent

As a client of PEOPLEinc. I am aware, and voluntarily choose, to participate in sessions to be held via teleconferencing. Every effort will be made to uphold strict confidentiality requirements as dictated by HIPPA. However, given the nature of this form of therapy, I realize, and willingly accept, the potential for a breach of confidentiality is at greater risk.
Patient Name*
First Last
Provider Name*
Please select from list
Date*
Date Format: MM slash DD slash YYYY
Your Signature*