Before signing this form, make sure that all of your questions and concerns have been addressed. Your signature indicates that you understand all of the policies and proce- dures described in Rainbow’s Consent for Evaluation & Treatment informational packet, and that you understand the following:
If two clients are seeing the same therapist together, please have the second client sign below.
By signing this form, you acknowledge receipt of the Notice of Privacy Practices that Rainbow Community Center Clinical Service Program has given you. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. You are encouraged to read it in full.
Our Notice of Privacy Practices is subject to change. If the notice is changed, you may obtain a copy of the revised notice from the Clinical Services Program by contacting us at (925) 692-0090.
If you have any questions about the Notice of Privacy Practices, please contact Rainbow Community Center: 2118 Willow Pass Rd. Ste. 500, Concord, CA, 94520.
I acknowledge receipt of the Notice of Privacy Practices of the Rainbow Community Center Clinical Services Program.