Care Consent and Privacy Form
Please complete this form to provide your consent and acknowledge our privacy practices regarding care intake.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Care Recipient
*
Please Select
Self
Parent/Guardian
Spouse/Partner
Child
Other Relative
Friend
Other
Preferred Contact Method
*
Email
Phone Call
Text Message
Purpose of Care Intake
*
Please Select
General Inquiry
New Care Enrollment
Update Existing Care
Request for Information
Other
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Consent to Share Information
*
Yes, I consent to share my information for care coordination purposes.
No, I do not consent.
Submit
Should be Empty: