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End of Adult Consent Form

Forms

Electronic Form Submission

Informed Consent for
Outpatient Services
& 
Notice 0f Privacy Practices

The following form will provide the information necessary to consent, understand our services at GFWC, provides important license information, understand that you have privacy, and that GFWC and yourself have responsibilities. Please be aware that this questionnaire requires sensitive information; as such please be aware of your privacy and complete this in confidential area. Likewise, upon submission of this information; your information is stored in a HIPAA compliant email address that is encrypted and password protected. Please allow 24-72 hours before a Clinician reaches out to assist with your intake via phone or telehealth.

Adult Client Section Only
(no pediatric clients)

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Health Insurance Information

Health Insurance Type:
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End of Adult Consent Form
scroll to the bottom of the page to submit this form.

Pediatric Client Section
(This section is for only children entering care NOT ADULTS)
Please have a Parent or Guardian fill out this Form

Health Insurance Type:
May we leave a (check all that apply):
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May we leave a (check all that apply):
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End of Pediatric/Child
Consent Form

Click here to download a copy of your form above

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