Patient Authorizations and Informed Consent

Name *
Name
Date *
Date
Parent One
Parent One
Parent Two
Parent Two
Informed Consent to Evaluation and Treatment
I (The Client) agree that the authorization shall serve as my informed consent to psychological evaluation and treatment with Dr. James Wellman.
Signed and Agreed *
Signed and Agreed
Your social security number will be used for digital authorization and signature
Date *
Date
Acknowledgement of Receipt of Notice of Policies and Practices to Protect the Privacy of My Health Information
I (The Client) acknowledge that I received notice to Dr. James Wellman's policies and practices to protect the privacy of my health information.
Signed and Agreed *
Signed and Agreed
Your social security number will be used for digital authorization and signature
Date *
Date
Authorization to Use Copies of This Document and Term of this Authorization
I (The Client) also permit a copy of this entire authorization to be used in place of the original. This entire authorization will remain in effect until revoked by me in writing.
Signed and Agreed *
Signed and Agreed
Your social security number will be used for digital authorization and signature
Date *
Date