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.
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 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 form
I attest that:
I acknowledge the following:
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.