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Intake Form (4)
Telehealth/Telemental Health Services Consent Form

Please read the following Telehealth/Telemental Health Services Consent Form and then complete and sign the form below.

This is the last of 4 sections you need to complete. Once you complete and submit the form below, you will receive a confirmation message confirming your form submission.  You may download a copy for your records below.

Please read the Notice of Privacy and Confidentiality Practices above before signing below.

Next Step

After you click “Submit,” you will be taken to a Confirmation Page to confirm that your intake paperwork has been submitted.

This is not a crisis line and is not monitored 24 hours a day. If you need immediate help, call 911 or 972-276-0057 to speak to a trained advocate on our 24-Hour Hotline.