Name: Date of Birth:
There may be times during therapy when my therapist wants to provide me with written information, such as a copy of my Service Plan. If the best way to get information to me is by email, I understand I have a choice to have emails sent securely to protect the information or sent unsecure to make it easier for me to access the information.
Please select one of the options below:
This document is being signed by: ClientPersonal Representative, see below
If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.
Full legal name of Personal Representative:
Relationship to client:
Definition of Personal Representative:For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Email Authorization
Agree & Sign