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People Inc.
Mental and Behavioral Health Treatment
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Vicki Adams
Erin Jacobson
Patrick Johnson
Valerie Dillon
Meghan Wilkins Melanson
Ishani Grover
Darcy Stewart
Patrick Scara
Denny Gunderson
Rick Grant
Gayle Ingalls
Donna Rhiver
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Patient Telehealth Consent
Patient Agreement Form
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Home
About Us
Our Team
Vicki Adams
Erin Jacobson
Patrick Johnson
Valerie Dillon
Meghan Wilkins Melanson
Ishani Grover
Darcy Stewart
Patrick Scara
Denny Gunderson
Rick Grant
Gayle Ingalls
Donna Rhiver
Services
Employment Opportunities
Client Info
Patient Telehealth Consent
Patient Agreement Form
Mental Health and Well Being
Rates and Insurance
New Client Forms
Blog
Contact
Contact Us
Authorization to Conduct Telehealth Sessions
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
*
Vicki Adams, LMHC
Patrick Johnson, PhD
Erin Jacobson, LMHC
Valerie Dillon, LMHC
Meghan Wilkins Melanson, LMHC
Ishani Grover, MA, LMHC
Darcy Stewart, LMHC, C-IAYT
Patrick Scara, LMFTA
Denny Gunderson, LMHC
Rick Grant, LMHC
Donna Rhiver, LiCSW
Please select from list
Date
*
Date Format: MM slash DD slash YYYY
Your Signature
*
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