Authorization Form

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

AUTHORIZATION FOR FACE-TO-FACE COUNSELINGDuring the Covid-19 Emergency Period

AUTHORIZATION FOR FACE-TO-FACE COUNSELING
During the Covid-19 Emergency Period