Dr. Shannon Francom, LMFT-S
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-- Client Information Form -- Informed Consent Agreement --
-- HIPAA Information --
Please complete this form and click "submit" at the bottom.
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Indicates required field
Full Name:
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Address:
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City:
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State:
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Zip Code:
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Phone Number:
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Email:
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Date of Birth:
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Age:
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Occupation (if applicable):
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Marital Status:
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Single
Married
Divorced
Separated
Widow/Widower
Cohabitating
Other
Spouse's/Partner's Name: (if applicable)
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Emergency Contact Information (will ONLY be used in case of an emergency):
Emergency Contact's Name:
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Emergency Contact's Number
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If applicable, please provide your children's names and dates of birth:
Child 1:
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Date of Birth:
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Child 2:
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Date of Birth:
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Child 3:
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Date of Birth:
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Child 4:
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Date of Birth:
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Child 5:
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Date of Birth:
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In your own words, what would you say is the presenting problem? Why have you decided to seek therapy, and why at this particular time?
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Click this
LINK
to access the Informed Consent and HIPAA Agreement.
(Then return to complete this page.)
Informed Consent Signature
By signing below, you are stating that you have read and understood the Informed Consent document (linked above), you understand the rules of and limits to confidentiality, and you accept the above-mentioned policies, fees, and informed consent. If 18 or older, as an adult, you are signing for yourself (or as a representative for a minor). [If under the age of 18, as a minor, you are aware that a representative will also be signing for you.]
HIPAA Signature
By signing below, you are stating you have read the information regarding your Patient Privacy Notice (HIPAA) (linked above), and are aware you may request a copy at any time.
Have you read, understood, and agree to the Informed Consent Agreement?
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Yes
Have you read the HIPAA information and are aware you may request a copy at any time?
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Yes
Signature
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Date
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Submit
Home
About Dr. Shannon
Therapy
Contact Me
FAQs
HIPAA
Schedule an Appointment