Virtual Session Counseling Liability Release Form
Please complete this form prior to your online counseling session. Your information will help us provide the best support and ensure you understand the limitations and responsibilities of virtual counseling.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Session Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Counselor or Provider Name
*
Counseling Service Type
*
Please Select
Individual Counseling
Couples Counseling
Family Counseling
Group Counseling
Other
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Brief Description of the Reason for Virtual Session
*
Liability Release and Acknowledgment
I understand that virtual counseling sessions have certain limitations, including potential technical issues and privacy limitations. I acknowledge that these sessions are not intended for emergency situations. I agree to participate in my session from a private and appropriate environment. By signing below, I release the counselor and counseling service from any liability related to technical difficulties, privacy limitations, or misuse of the virtual counseling service.
Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: