whose email is:
hereby consent to participate in telemental
health with LifeSolutions Counseling Associates, PC as part of my mental health services. I understand that telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.
I understand the following with respect to telemental health:
to discuss since we may have to re-schedule.
I need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency.
In case of an emergency, my location is:
and my emergency contact person’s name, address, phone:
I have read the information provided above and discussed it with my mental health professional. I understand the information contained in this form and all of my questions have been answered to my satisfaction.
LifeSolutions provides professional services that will help improve your mind, spirit, and wellness in life.
Call (317) 569-5433 Today.
We’re Here To Help.
Old Meridian Professional Center1185 W. Carmel DriveSuite D-4Carmel, IN 46032(317) 569-5433
Riverview Medical Arts14540 Prairie LakesBoulevard North Suite 202Noblesville, IN 46060(317) 569-5433
Beginning April 19, 2021, all client information, forms, and balances can be viewed from a New Client Portal. You will receive access to this New Client Portal via two emails, one providing you with your user name and one providing you with a temporary password and a link to the New Client Portal. Please contact support staff with any questions at 317-569-5433.