Disclosure Receipt

Center for Counseling, Healing & Growth

Reunion

I acknowledge that I have received and read the following disclosures: *

Beacon Member Rights

Beacon Privacy Practices

Telehealth Information Form

Telehealth Consent Form

Email:

Date

I agree my electronic signature is the legal equivalent of my manual signature. *

Name:

I acknowledge that I have received and read the following Disclosures.