Bereavement Informed Consent
CONSENT FOR SERVICES: I hereby voluntarily consent to Trustbridge Bereavement Center to provide bereavement grief support services, including (but are not necessarily limited to) individual support, group support, virtual sessions, or education by employees or authorized agents of Trustbridge, Inc. CONFIDENTIALITY/PATIENT RIGHTS: I understand that Trustbridge Bereavement Center clinicians maintain confidentiality of client information in accordance with the Health Insurance Portability and Accountability Act (“HIPAA”) and other applicable, Federal, State and other regulations. I understand that if I choose to participate in a virtual session, it is my responsibility to be in a private room or space and if not, my conversations may be overheard by others. I have been informed of my rights and have received a copy of Trustbridge’s Notice of Privacy Practices and Patient Rights & Responsibilities.
Name of Client/Participant
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First Name
Last Name
Client Date of Birth
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Name of Parent/Guardian
First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
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Consent
I consent to treatment and authorize this to serve as my signature
Submit
Should be Empty: