Patient Authorizations and Informed Consent

Name

First Name

Last Name

Date

YYYY

Parent One

First Name

Last Name

Parent Two

First Name

Last Name

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

First Name

Last Name

Digital Signature

Your social security number will be used for digital authorization and signature

Date

YYYY

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

First Name

Last Name

Digital Signature

Your social security number will be used for digital authorization and signature

Date

YYYY

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

First Name

Last Name

Digital Signature

Your social security number will be used for digital authorization and signature

Date

YYYY