Authorizations

  • Informed Consent for Evaluation and Treatment

    I understand and consent to an evaluation and recommended treatment plan. I will be informed of all risks and benefits of any treatment plans prior to implementation. I can choose to not have the recommended treatment plan. If I choose to decline a specific recommended treatment plan I will be asked to acknowledge that in writing.
  • Pictures/Video Recordings/Audio Recordings:

    I give indicated authorizations for photographs/video recordings/audio recordings of the client for evaluative and/or therapeutic purposes only by Honey Bee Health Collective staff. The following devices may be used but are not limited to: a Honey Bee Health Collective tablet/computer/camera, or therapist’s personal phone/tablet/computer/camera. All photos/recordings made on a personal device will be transferred/uploaded to a Honey Bee Health Collective flash drive, computer, or clients electronic medical record chart and securely deleted from the privately used device. All photos/recordings will be securely destroyed at parent/client request or upon termination of services.
  • This does not give permission for photos/video recording/audio recording to be posted on any of Honey Bee Health Collective's website or other social media. A separate permission will be obtain for any website or social media purposes.
  • Confidential Information

    I understand that confidential, protected information will not be left on my or any designated authorized contact person’s voicemail, text messaging, email, or other electronic medium unless I have requested such in writing.
  • General Communication

    I authorize to receiving, including but not limited to: phone calls, emails, texts re: appointment/scheduling reminders, office notifications, no show messages, etc. that does not include any confidential, protected healthcare information.
  • Patient Responsibilities

    I received a copy of the Honey Bee Health Collective Patient Responsibilities
  • By signing below, I have confirmed that I have provided accurate information to the best of my knowledge and accept all areas indicated
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