Service Policies Acknowledgement Form

Client Name *

Date of Birth *

Are you under the age of 18? *

Yes
No

By Initialing and signing below, I attest that I have been provided with the documents outlined below by a Families Matter Counseling and Consultation Services, LLC Providers for any and all services provided and that they have explained these documents to me in a manner and language that I understand. I also understand that I have the right to ask questions, end services and report to end services that I feel are not appropriate for me without fear of retaliation or losing services. I also understand that I have a right to receive copies of any documents that I have signed below for my records in accordance to the law.

that by ask

Client initial for each policy:

Statement of Client’s Rights and Responsibilities *

Policy on all types of provider Communications including Telehealth policy *

Policy Consent and Limits of Confidentiality for any services Provided *

Notice of Privacy Practices and Complaint Procedures *

Emergency on call procedures *

Clinician Email

Client signature

Clear Signature

Date

Provider signature *

Clear Signature

Date *