EBHS Behavioral Health Consent Form

Patient Phone Patient

Patient Name

First

Last

Date of Birth

Patient Email

Patient Phone Number

Patient Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Name

Emergency Contact Phone Number

Telehealth Consent and Acknowledgements

I consent to receive behavioral health services via telehealth from Effect Behavioral Health Solutions.
I understand telehealth involves communication by video and/or phone and may be different than in-person care.
I understand there are potential risks to privacy or technical failures and that reasonable safeguards will be used.
I understand I may stop telehealth services at any time and can request in-person services when available.

Additional Information or Questions

Patient/Client Signature

Clear Signature

Consent Date