Permission to Release / Exchange Information (Coordination of Care)
The undersigned has read the Coordination of Care section of the Welcome packet and gives permission to have Sasco River Center, LLC contact and discuss Client’s case with: SRC professionals, and all persons whose names I have provided as professionals working with the Client on the contact page / clinical intake form, and/or those additionally listed below.
Acknowledgment of Risk
The undersigned acknowledges that there is some risk inherent in the use of the therapy equipment at Sasco River Center, LLC and I agree to indemnify and hold Sasco River Center, LLC harmless from any and all losses and claims for any injuries occurring to the Client from the use of therapeutic equipment.
Consent for Email and/or Text Messaging
The undersigned understands that when sending and/or receiving emails or text messages, there is a risk that a third party may be able to access the information and read it. Sasco River Center has no control over the platform receiving the email or what happens to the email between our server and yours. Similarly, information shared via text message can also be intercepted if someone gains unauthorized access to a provider’s cell phone or your cell phone. Please indicate your communication preference here. Note that this preference can be changed by you at any time.
Student observations
On occasion, Sasco River Center has interns and/or students complete part of their training with us. By checking the box below, the undersigned gives permission for interns and/or students to observe Client's therapy. Either way, I would be notified prior to the intern/student beginning their affiliation.
Commitment to Inclusivity: Sasco River Center is an equal opportunity organization, and does not discriminate on the basis of race, age, ethnicity, ancestry, national origin, disability, color, size, religion, gender, sexual orientation, marital status, or socioeconomic background. We are committed to providing an inclusive and welcoming environment for all clients and colleagues.