Gurnee Counseling Center -Telephone Contact Permission Form

TELEPHONE CONTACT PERMISSION FORM
Please complete this form prior to your first appointment. It will need to be signed on your first visit to our office.

Name
Email
	Occasionally, we may find that we need to contact you regarding your appointments or your account. In an effort to protect your privacy, please fill out the following questionnaire on what would be the best way to contact you personally.
May we contact you regarding your appointments or your account? Yes No
At which number do you prefer to be contacted?
Home		Home phone number
Cell		Cell phone number
Work		Work phone number
If you are unavailable, may we leave a message on your voicemail/answering machine?
Home
Cell
Work
If you are not home, may we leave the message with someone at your residence? Yes No
Person to contact in the event of an emergency:
Name
Phone
Relationship
If we do not have this form on file, we will NOT call you to remind you of your appointments or any matters regarding your account. You will be notified via mail should the need arise. __________________________________________(signature) _________________(date) By submitting this form via email, you agree that the information above is correct. We will require your signature on a hard copy at the time of your first appointment.

HOME | EMAIL | NEWSLETTER

Gurnee Counseling Center
4212 Old Grand Avenue, Suite 102, Gurnee, Illinois 60031
P: 847.336.5621 F: 847.336.2594

web development : cooperdesign.net

TELEPHONE CONTACT PERMISSION FORM Please complete this form prior to your first appointment. It will need to be signed on your first visit to our office.

TELEPHONE CONTACT PERMISSION FORM
Please complete this form prior to your first appointment. It will need to be signed on your first visit to our office.