Skip links

Telehealth Consent Form

To ensure a safe, informed, and comfortable experience, we ask all clients participating in virtual sessions to complete this Telehealth Consent Form. At Ariza Wellness, we offer therapy and mental health services through secure, HIPAA-compliant video platforms. This form outlines your rights, responsibilities, and important details about how telehealth works, including privacy protections, emergency procedures, and technology requirements. By completing this form, you confirm your understanding of and agreement to receive care via telehealth. If you have any questions, our team is happy to assist you before your session.

🔒 Your information is kept private and secure in accordance with federal and state confidentiality laws.

Please enable JavaScript in your browser to complete this form.
Address
Consent Statement
Telehealth Risks & Benefits Acknowledgment
Emergency Plan Acknowledgment
Technology Use

Consent & Signature

Clear Signature
Privacy Overview

This website uses cookies so that we can provide you with the best user experience possible. Cookie information is stored in your browser and performs functions such as recognising you when you return to our website and helping our team to understand which sections of the website you find most interesting and useful.