Authorization to Conduct Telehealth Sessions

"*" indicates required fields

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 HIPAA. 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*
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