SASSNA New Client Intake Packet
This form allows for our clients to electronically complete and sign the Client Confidentiality Statements and Agreement on page one (1) of our intake packet and the Notice of Privacy Practices Client Acknowledgment on page eight (8) of our intake packet. The form is secure. We ask for your e-mail address below so that a copy of what you enter in this form can be e-mailed to you.
Email address *
Please enter the full name/s of the young person/s with a disability or possible disability that is/are our new client/s. *
If there are multiple young persons then please enter all of their full names here. Separate each name with a comma.
Your answer
Please enter the full name of the person completing this form right now. *
Only one person at a time is allowed to complete the form, so enter only one name here.
Your answer
Please indicate today's date. *
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YYYY
Please sign both the Client Confidentiality Statements and Agreement on page one (1) of our intake packet and the Notice of Privacy Practices Client Acknowledgment on page eight (8) of our packet by typing your full name, date of birth, and full address (not e-mail address). This acts as your signature. *
By entering your full name, date of birth, and full address (not e-mail address) you are signing both the Client Confidentiality Statements and Agreement on page one (1) of our intake packet and the Notice of Privacy Practices Client Acknowledgment on page eight (8) of our packet. You must enter all three of the requested items - name, date of birth, and address. Please enter them clearly and accurately. Only one person at a time is allowed to complete this form, so enter only one person's information/signature here.The information you provide is secure in this form and is kept confidential by SASSNA.
Your answer
Thank you for choosing us to serve you.
A copy of your responses will be emailed to the address you provided.
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