August 20, 2018 by STRRGLMBWSK4923842345

CORRECT Consent to Treatment Form

Name *

E-mail *

Phone *

Message

E-mails requesting more information about the therapist, including scheduling and availability, do not constitute a relationship with the therapist. Also, while convenient, electronic communication is not 100 percent secure, so please keep this in mind should you decide to email or text this therapist. Starr@starrtherapy.org is a HIPAA compliant email address; however, emailing from the starrtherapy.org website or your own personal account may not have this same level of security. If you wish to keep your information more secure, please call rather than text or email. Voicemail messages are typically responded to in 72 hours.

Yes, I want to submit this form

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Message

CORRECT Consent to Treatment Form

Office Hours

Find My Office

Contact Information