top of page

Please reach out to book a free consultation

Phoebe Montgomery, MSW, RSW

Home
- Considerations for Online Therapy
About
Services
Blog
Contact

Informed Consent to Treatment

Please fill out the following form
in order to participate in counselling

First name

Last name

Email

Date of Birth

Phone

Did you review the Consent Form Emailed to you? *

Yes

No

If you have any questions regarding the contents of the form please elaborate:

Select an option *

I have questions and would like to discuss the form further before proceeding with Individual Counselling.

I have read and fully understand the information contained in this document. Any and all questions I have regarding the contents of this document have been answered to my satisfaction and I would like to proceed with counselling services from Phoebe Montgomery, MSW RSW..

Initials

I declare that the info I’ve provided is accurate & complete

Your Signature

Thanks for submitting!

© 2023 by Phoebe Montgomery, MSW, RSW, Powered and secured by Wix

bottom of page