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AUTHORIZATION FOR FACE-TO-FACE COUNSELING
During the Covid-19 Emergency Period
Based on my professional assessment, the client
*
Indicates required field
Client's Name
*
First
Last
Diagnosis
*
Date of Birth
*
requires face-to-face counseling as the most appropriate delivery of services. Telehealth counseling would not be the best practice in this case because of:
Choose One
*
MENTAL HEALTH RISK
THERAPEUTIC NEED
IT IS NOT LOGISTICALLY FEASIBLE
THEY ARE A NEW CLIENT
In a sentence describe the condition making face-to-face counseling necessary.
Description
*
CLINICIAN:
*
First
Last
Date submitted
*
Submit