Medical New Patient Information and Privacy Consent Form

SCA TREATMENT AGREEMENT
Shelby Counseling's main form of communication is email. This includes but is not limited to invoices, insurance updates, and statements. I am responsible for checking and updating my email address with SCA.*

Yes, I agreeNo, I do not wish to receive services from SCA
Signature of Client (Parent or Guardian if under 18)*

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Name of Signer*

First NameLast Name
Today's Date