Medical New Patient Information and Privacy Consent Form

SCA TREATMENT AGREEMENT
Primary Communication MethodShelby Counseling Associates primarily communicates via email. This includes, but is not limited to:InvoicesInsurance updatesStatementsClients are responsible for checking and updating their email address with SCA to ensure they receive all necessary communications.*

Yes, I agreeNo, I do not wish to receive services from SCA
Signature of Client (Parent or Guardian if under 18)*

Clear
Name of Signer*

First NameLast Name
Today's Date