During the 21 day lockdown in order to curb the spread of Clovid-19, we will be conducting all consultations electronically via Zoom.
This document needs to be signed in conjunction with the Informed Adult/Adolescent Consent Document.
I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment, nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
Jenine Smith Inc. Online Psychotherapy services are not for minors.
Recordings Are Prohibited:
Risk of Harm:
No Shows or Late Cancellations:
I understand the risks and limitations to online psychotherapy. By signing this consent, I agree to abide by its
This is not an actual appointment form. The below form is to request an appointment. We will get back to you to confirm if the requested date and time is available.