Consent Form

This form is an agreement between you, and Calvary Counseling Center. When we use the word “you” below, it will mean you, your child, relative, or other person if you have written his or her name below:

Name

When we examine, diagnose, treat, or refer you, we will be collecting what the law calls Protected Health Information (PHI) about you. We need to use this information to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions. By signing this form you are agreeing to let us use your information here. The Notice of Privacy Practices explains in more detail your rights and how we can use and share your information. Please read this before you sign the consent form.

If you do not sign this consent agreeing to what is in our Notice of Privacy Practices, we cannot treat you.

In the future, we may change how we use and share your information and so may change our Notice of Privacy Practices. If we do change it, you can get a copy by calling us at 703-530-9800, or from our privacy officer. If you are concerned about some of your information, you have the right to ask us to not use or share some of your information for treatment, payment or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to agree to these limitations.

After you have signed this consent, you have the right to revoke it (by writing a letter telling us you no longer consent) and we will comply with your wishes about using or sharing your information from that time on; but we may already have used or shared some of your information and cannot change that.

Digital Signature of client or his/her personal representative

Date

Home Phone

Cell Phone

Consent Form

Consent Form

Calvary Counseling

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