Intake & Consent Forms - Client Self Service

Please fill out the following form. Once you have completed the form, click on "Proceed to Signature Page" and you'll be taken to a new page where you'll sign the consent forms.



  • Client Details

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  • This may be the client or the parent/guardian


  • Mental Health Services Agreement

  • PERMISSION FOR TREATMENT

    I agree to permit employees of ANOD INC to provide services to me. I understand that ANOD INC can make no guarantees about the outcome of my treatment, but that I can expect to receive services that are ethical and professional.

    I understand that ANOD INC agrees to comply with all privacy laws and respects my right to confidentiality. As a client, I agree to attempt to be honest and to disclose information to assist the ANOD staff in providing appropriate services.

    1. I agree to attend scheduled appointments or notify service providers if I need to reschedule an appointment.

    2. I agree to participate in treatment planning, that is, developing and implementing a functional assessment and individual treatment plan.



  • Client Rights & Responsibilities

  • CLIENT RIGHTS AND RESPONSIBILITIES FOR EIDBI RECIPIENTS

    Please click the link below to be taken to the DHS Client Rights & Responsibilities Document for review. Once you read through that document, please come back to this page to acknowledge your agreement. 

    DHS EIDBI Client Rights and Responsibilities

    Your signature in the field below indicates your acknowledgement of the rights and responsibilities as stated on the DHS 7645A. Your signature will be transferred to that form.



  • EIDBI provider agency responsibilities

  • EIDBI provider agency responsibilities form

  • COVID-19 Liability Waiver

  • COVID-19 Liability Waiver

    I attest that:

    • I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or
    • I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
    • I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by state or local public health
    • I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
    • I have not traveled internationally within the last 14
    • I have not traveled to a highly impacted area within the United States of America in the last 14 days. If so, please tell us where you traveled to and your dates of travel.

    I acknowledge the following:

    • The contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social
    • ANOD Inc has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
    • ANOD Inc cannot guarantee that I will not become infected with the Coronavirus/COVID-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, counseling staff, and other clients and their families.
    • I voluntarily seek services provided by ANOD Inc and understand that I am increasing my risk to exposure to the Coronavirus/COVID-19.
    • I will comply with all set procedures to reduce the spread while attending my appointment.

    I hereby release and agree to hold ANOD Inc harmless from, and waive on behalf of myself any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the counseling practice, or that may otherwise arise in any way in connection with any services received from ANOD Inc. I understand that this release discharges ANOD Inc from any liability or claim that I, my heirs, or any personal representatives may have against the practice with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from ANOD Inc. This liability waiver and release extends to the counseling practice together with all therapists and other employees.

  • This field is for validation purposes and should be left unchanged.