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Curtis Trent, MA, MHC Licensed Mental Health Counselor License # 39002142A 7526 E 82nd St., Suite 150 Indianapolis, IN 46256 3175851060 http://www.fcahelp.com DISCLOSURE STATEMENT & INFORMED CONSENT
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Begin by carefully reviewing the form: Take your time to read through the form and understand each section and its purpose. This will help ensure that you provide accurate information.
02
Personal Information: Start by filling out your personal information section, which may include your full name, address, phone number, email address, and any other relevant contact details.
03
Consent for Treatment: This section typically requires you to provide your informed consent for any medical treatment or procedures that may be necessary. Read each statement carefully and indicate your consent where required.
04
Medical History: Fill in your medical history accurately and in detail. This may include any existing medical conditions, allergies, surgeries, medications, and any other relevant health information. Provide as much information as possible to help the healthcare provider make informed decisions.
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Emergency Contact: Provide the name, relationship, and contact details of the person you would like to be contacted in case of an emergency.
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curtis-trent-informed-consent-intake-formpdf is a consent form provided by Curtis Trent for intake purposes.
Any individual who is seeking services from Curtis Trent may be required to file the informed consent intake form.
The form can be filled out by providing personal information, signing to indicate consent, and answering any relevant questions.
The purpose of the form is to ensure that individuals understand and consent to the services provided by Curtis Trent.
Personal information, consent for services, and any relevant medical or psychological history may need to be reported on the form.
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