Skip to content
CONTACT US TO SCHEDULE AN APPOINTMENT
Home
Services
Therapists
FAQ’s
Ravenswood Therapy Group
About Us
Contact
Forms
Ravenswood Therapy Group
Home
Services
Therapists
FAQ’s
About Us
Contact
Forms
Receipt and Acknowledgement of Notice of Privacy Practices
Name:
(Required)
First
Last
Date of Birth:
(Required)
Month
Day
Year
Date
Month
Day
Year
Signature of Client:
(Required)
Reset signature
Signature locked. Reset to sign again
Signature of Parent or Legal Representative:
(Required)
Reset signature
Signature locked. Reset to sign again
Relationship to Client:
Consent:
Client Refuses to Acknowledge Receipt:
Date
Month
Day
Year
Signature of Staff Person:
Reset signature
Signature locked. Reset to sign again
