Acknowledgement Form in Austin, TX | Austin Mind and Behavioral Health

Acknowledgement Form

I, the undersigned, for a minor (under the legal age of 18), for whom I am the legal guardian, or for myself, hereby affirm that:

I have read and fully understand Austin Mind and Behavioral Health Office policies, and I agree to abide by them.

I have read the Notice of Privacy Practices on the website and know that I can request to receive an electronic or paper copy.
Name of Patient or Minor*
First Last
Date of birth*
MM slash DD slash YYYY
Relation to person providing consent*
I certify that I have read and fully understand the above statements and that I am providing this declaration voluntarily, without any coercion. ( Signature of Legal Guardian/Self )*
Date*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.