SCC Consent for Treatment and Release of Information

I understand, agree and/or give permission to the following by checking the box with each statement below:

Name Name * First Last
Date of Birth Date of Birth * / MM / DD YYYY
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone * - ### - ### ####
Cell Phone Cell Phone * - ### - ### ####
Email *
To receive services from Spiritual Care Consultants of West Michigan (SCC), a tax exempt, non-profit organization. I understand that SCC is a Christ Based Consulting Ministry. We do not offer counseling service. *

To receive services from Spiritual Care Consultants of West Michigan (SCC), a tax exempt, non-profit organization. I understand that SCC is a Christ Based Consulting Ministry. We do not offer counseling service. Yes No
My participation in the SCC program is voluntary and free of charge. Any donations made to SCC are purely voluntary and not a payment for services. *

My participation in the SCC program is voluntary and free of charge. Any donations made to SCC are purely voluntary and not a payment for services. Yes No
I can discontinue my participation with SCC at any time and I don’t have to agree with any advice given. I have the freedom and responsibility to make my own choices and resultant consequences. *

I can discontinue my participation with SCC at any time and I don’t have to agree with any advice given. I have the freedom and responsibility to make my own choices and resultant consequences. Yes No
There are three items that are limited in confidentiality: child abuse, threatening to harm self, or threatening to harm another person. These must be reported to the proper authorities. *

There are three items that are limited in confidentiality: child abuse, threatening to harm self, or threatening to harm another person. These must be reported to the proper authorities. Yes No
Information may be collected from and/or shared with my physician, other treatment providers, or Employer (if referred by them) during and after my sessions for coordination of care and/or evaluation purposes. I understand that information collected is confidential, according to HIPAA regulations. *

Information may be collected from and/or shared with my physician, other treatment providers, or Employer (if referred by them) during and after my sessions for coordination of care and/or evaluation purposes. I understand that information collected is confidential, according to HIPAA regulations. Yes No
My treatment information may be used for future research studies, which are for the sole purpose of providing optimal care for all clients. I understand that information collected is confidential and will be reported by researchers in total numbers only, with no identifying information revealed. *

My treatment information may be used for future research studies, which are for the sole purpose of providing optimal care for all clients. I understand that information collected is confidential and will be reported by researchers in total numbers only, with no identifying information revealed. Yes No

SCC has permission to use any pictures drawn or colored, writings of poems, stories, or testimonials, or photographs taken of me in or out of session with SCC. Material may be shared in both written and social media forms for the sole purpose of promoting SCC and (may / may not) include my *
	Yes	No	Second option	Third option
Agree	AgreeYes	AgreeNo	AgreeSecond option	AgreeThird option
May/May Not	May/May NotYes	May/May NotNo	May/May NotSecond option	May/May NotThird option

(Parent or Guardian, if under 18 years of age) *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date * / MM / DD YYYY
Witness (SCC Consultant)