Informed consentPlease complete the form below: Patient Information * First Name Last Name DOB * Age Sex Home Address City, State and Zip Phone * (###) ### #### Email * Emergency Contact: * First Name Last Name Emergency Phone * If the client is under 18 years of age, please complete the following fields: Parent/Guardian #1: First Name Last Name Parent/Guardian #1 DOB: Parent/Guardian #1 Age: Parent/ Guardian #1 Home Address: Parent/Guardian #1 relationship to patient: Parent/Guardian #1 phone number: Parent/Guardian #2: First Name Last Name Parent/Guardian #2 DOB: Parent/Guardian #2 Age: Parent/Guardian #2 home address: Parent/Guardian #2 relationship to patient: Parent/Guardian #2 phone number: Payment Information Alliance requires a credit card be saved on file to be billed for each appointment. You will only be charged for attended appointments or unattended appointments that are not canceled with more than twenty-four-hour notice (see cancelation policy). We will provide you with a receipt for charges upon request. Name on card: * Card number: * Expiration Date: * CVV: * Zip code: * I authorize Alliance and its representatives to charge my card for services provided or unattended appointments not canceled with more than twenty-four-hour notice. In the event of a dispute regarding charges, I authorize Alliance to provide information to relevant financial institutions regarding the charges in dispute. * I authorize I understand that I am financially responsible for all charges as Alliance does not accept nor bill insurance. Full payment is due at the time of service. * I understand About Telemental Health Services: I understand that there are risks and benefits unique to telemental healthcare as described in this page * I understand Notice of Privacy Rights & Policies: I have read and understand my privacy rights and acknowledge the policies set forth as described in this page. * I understand Consultation and Case Conference: please select if you consent for your provider to present your case in a case conference as described in this page. * I DO NOT consent to have my information presented at an Alliance case conference. I consent to have my information presented at an Alliance case conference. Communicating Via Email & Text: please select if you consent to any form of electronic communication as described in this page. * I DO NOT consent to any form of electronic communication. I consent to email communication I consent to communication by text message By checking the box and submitting this form you indicate that you have received, read, understand and are willing to abide by the policies and terms of this page’s content. You also attest to having the legal rights and authority to consent for mental health treatment for the patient if they are a minor. * I understand Thank you!
