Electronic Signature - Blissful Therapy

Informed Consent, Privacy Practices, and Client Demographics Electronic Signature

Use this page to give your consent to therapy instead of downloading forms and scanning or sending pictures of them back by email.

The following blanks are to be filled out as your Agreement to the Informed Consent, Privacy Practices, Telehealth Disclosures, and Client Demographics found on the forms page. You may download, read and save the forms found on that page for your records. If requested, I can send you a confirmation email with your signature sent by you here.

Please be aware and informed that information you send over the internet may not be completely confidential as data breaches have been known to occur over the internet even with password protection, encryption, and other data safety measures I have taken.

First name, last name, and Gender (Any Orientation or Special Pronouns?):

Address including city, state, and zip code

Your email

Emergency Contact Name and Number:

Your phone

Date of Birth

Name of Insurance, Policy & Group Number and Mental Health Phone Number from Back of Card:

Your Goals for Therapy

By checking this box and submitting your information, you are stating that you read and understand as well as signing your agreement to the Informed Consent, Privacy Practices, telehealth disclosures and giving your information for Dr. Adrianne Bliss-Williams to contact you (by mail, email, or phone numbers provided) and your insurance company for therapeutic counseling services. You may revoke your permission at any time in writing or verbally.

Message Sent!

Your message has been sent successfully, I hope to respond within one regular business day. You can also contact me through social media, links can be found below!