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Client Agreement

E-THERAPY SUITABILITY FORM

All of the information that I have reported in the patient contact form is true.
In the event that WhidbeyCounseling.com believes that I am at risk of harming others or myself, WhidbeyCounseling.com has my full permission to notify the local ermergency services and support contacts that I listed on the patient contact form.
I agree to pay all fees for the services of WhidbeyCounseling.com. I agree to all additional fees that may be incurred in the collection of monies owed WhidbeyCounseling.com
Digitally Sign Your Name:(required)
Todays Date:(required)
Enter the text from the box on the right.

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