Client's Rights and Responsibilities Notice of Privacy Practices Grievance/Complaint Procedure Missed Appointment Policy Date* Date Format: MM slash DD slash YYYY Client Name* First Last Name of Parent, Guardian, or Personal Representative(if applicable) First Last Relationship to ClientHome PhoneWork PhoneCell PhoneEmail* Enter Email Confirm Email Documents Received* I have received a copy of, read, and understand the following documents:• Client's Rights and Responsibilities • Notice of Privacy Practices • Grievance/Complaint Procedure • Missed Appointment PolicyStatement of Understanding* I understand that if I have questions I can ask my counselor or another ZVHC staff person.Communication Consent* I authorize Zumbro Valley Health Center to contact me, whenever needed, for any reason pertaining to my services by:Please select all that apply:* Select All Home Phone Work Phone Text Email
