Consent form – Parents' Coach Network

Name *

First

Last

Cell Phone Number *

Email *

Dr's name and phone number (optional)

Please check the following boxes to consent: *

I consent to receive counselling/psychotherapy from the Parents’ Coach Network and I have the right to withdraw my consent at any time.
I acknowledge that all health information collected is private and confidential. I give permission to receive and disclose my health information within the team of the Parents’ Coach Network and other health care professionals if necessary for consultation purposes.
I acknowledge that the Parents’ Coach Network is not an emergency service. I will call 911 or go to the nearest hospital in case of a mental health crisis.
I acknowledge that I will give 24 hours' notice to cancel my appointment or a full session fee will be charged.

Please type your name if you agree with the above *