Adult - Fin. Updated Client Paperwork (Adults) - w/out Financial Information

Client Information, Informed Consent,
and HIPAA Agreement

Please update all of your information and click "submit" at the bottom.

Client Information

* Indicates required field

Full Name: *

Address: *

City: *

State: *

Zip Code: *

Phone Number: *

Email: *

Date of Birth: *

Age: *

Occupation (if applicable): *

Spouse's/Partner's Name: (if applicable) *

Emergency Contact Information (will ONLY be used in case of an emergency):

Emergency Contact's Name: *

Emergency Contact's Number *

If applicable, please provide your children's names and dates of birth:

Child 1: *

Date of Birth: *

Child 2: *

Date of Birth: *

Child 3: *

Date of Birth: *

Child 4: *

Date of Birth: *

Child 5: *

Date of Birth: *

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? *

Informed Consent, HIPAA Agreement, and Office Policies and Procedures

*To access a copy of the Informed Consent, HIPAA Agreement, and Office Policies and Procedures, click this link.

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? *

Yes

Have you read the HIPAA information and are aware you may request a copy at any time? *

Yes

Signature *

Date *

Submit

Updated Client Paperwork (Adults)

Client Information

Informed Consent, HIPAA Agreement, and Office Policies and Procedures

Dr. Shannon Francom, LMFT-Sand Associates

Dr. Shannon Francom, LMFT-S
and Associates