New Life Counseling 

130 West 3rd Street, Dover, OH 44622

Phone: 330-343-6600

Email: newlife@newlifedover.com

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© 2019 | New Life Counseling 

TELEHEALTH CONSENT FORM

We are required by law to provide you with informed consent, which we will do through the review and signature of an informed consent form. The form is attached to this email. Please review it and return it with your signature, as we HAVE to have this before your appointment.

This can be accomplished in one of several ways.

  1. You can print it, sign it, scan it, and email it back.

  2. You can print it, sign it, and take a picture of the signed third page, with your name and signature clearly showing and either email us or send it via text message to 330.597.0066.

  3. You can read the form, and text or email your agreement, acceptance, and validation of your identity in a separate message: please see the example below. Please note if you use this method, you must include the set of random digits in the box at the bottom of the last page of the consent form to validate that you have accessed the document.

Example response:

“I have read and understood the New Life Counseling telehealth consent form, and I accept it, agree to accept the risks it outlines, and certify I am the client or the client’s parent/guardian.  This message constitutes my electronic signature for that document.” [Random number sequence here]