Peninsula Pastoral Counseling Center

Consent Forms

 
Client Name *
 
Client Date of Birth *
 

Client Rights and Responsibilities

As our client, you have several rights and responsibilities. Please review rights and responsibilities here.

I have read and understand my rights and responsiblities. *  No   Yes 
 

Financial Policy

Please review our Financial Policy here.

I have read, understand and accept PPCC's Financial Policy. *  No   Yes 
 

HIPAA Privacy

Please review the HIPAA Notice of Privacy Policies here.

I acknowledge that I received, read and understand the HIPAA Notice of Privacy Policies. *  No   Yes 
 

Consent to Treatment for Children

Please review the Consent to Treatment for Minors here.

I have read the Consent to Treatment form and hereby consent to treatment. *  No   Yes   Not Applicable (n/a) 
 

Consent to Treatment for Adults

Please review the Consent to Treatment for Adults here.

I have read the Consent to Treatment form and hereby consent to treatment. *  No   Yes   Not Applicable (n/a) 
 

Consent to VideoTherapy

Please review our Consent to VideoTherapy here.

I have read and understand the Consent to VideoTherapy form hereby give my consent for the use of VideoTherapy in my medical care. *  No   Yes   Not Applicable (n/a) 
 

Sign and Submit