RYWC
Home
About
Outreach Program
Psychotherapy
Client Centered Care
Expressive Art Program
Consultation
Contact Us
Online Registration
Home
About
Outreach Program
Psychotherapy
Client Centered Care
Expressive Art Program
Consultation
Contact Us
Online Registration
Online registration
*
Indicates required field
Client Name or Name of Parent/ Guardian
*
First
Last
Insurance Provider & Member ID: Phone Number: Child Name & DOB (If applicable)
*
Date of Birth /Social Security Number
*
Treatment Planning (Select one)
*
Housing
Mood Regulation
Coping with Physical Health
Parenting
Communication skills
Trauma
School/Work
Depression
Anxiety
Divorce
Foster Care
Financial Stability
Type Name for Signature and Date (Example Jane Doe 08/01/2022)
*
It is the policy of RYWC to use and disclose protected health information for treatment, payment and health care operations reasons.
I hereby consent to engage in telehealth (e.g., internet or telephone based therapy) as a potential venue for my psychotherapy treatment. I understand that telehealth includes the practice of health care delivery, including mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communications.
I acknowledge that by completing this form and hitting submit that I am submitting my electronic signature and giving my consent for services.
Submit electronic signature for Consent/Treatment