Consent form – Parents' Coach Network

Name *

First

Last

Address *

Cell Phone Number *

Email *

Dctor's name and phone number

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, go to the nearest hospital, or call 988 mental health crisis line in case of an emergency.
I acknowledge that I will give 48-hour notice to cancel my appointment or a full session fee will be charged.

Signature *