21 Client Consent Form Client Name(Required) First Last Birth date(Required) MM slash DD slash YYYY Previous Name(s) First Last Marital Status Single Married Divorced Legally Seperated Widowed The following policies have been given to me or can be found at smnbh.org HIPAA Notice of Privacy Practices Client Payment Policy Missed Appointment Policy Please provide your signature and date in regard to the following five items: Consent for Insurance Billing I allow Southern Minnesota Behavioral Health to submit insurance claims on my behalf.Consent for TreatmentI understand that I will be given appropriate information by my therapist about mental health therapy, psychological testing, and related procedures that may be offered to me at Southern Minnesota Behavioral Health. This will include a description of the nature, purpose, and probability of success of the recommended treatment, and any attendant risks. I here freely give my consent to treatment.Consent for Appointment Reminders I allow Southern MN Behavioral Health to send appointment text reminders unless I do not have text capabilitiesPhoneReceive Text messages I can receive text messages I CANNOT receive text messages Consent for Telehealth Appointments I consent to telehealth services.Email Address Signature(Required) First Last Date MM slash DD slash YYYY If Client can not sign First Last Relationship to Client Race African American American Indian Asian Pacific Islander White Hispanic Other Specify Do you smoke Yes No What is the primary language spoken in your home? Would you say you speak English Very Well Well Not well Not at All CAPTCHA
