STAY AND TALK - CONSENT FORM

***If you prefer, this is available in a PDF that you can print, sign and upload. If you do not have access to a printer, you may copy/paste, and send via email. ****

COPY AND PASTE THE FOLLOWING INTO AN EMAIL AND SEND TO TYLER@STAYANDTALK.COM 

SUBJECT OF EMAIL: Stay and Talk Consent Form – YOUR FULL NAME

Full Name:

Date of Birth:

Phone Number:

Email Address:

Emergency Contact Name:

Emergency Contact Phone Number:

Relationship to You:

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1. **Consent to Services**

I understand that I am voluntarily engaging in free support services with Tyler Zenz, MA, LAC through Stay and Talk. These services may include individual counseling, support, and/or substance use assessments. I understand these services are not a substitute for medical or psychiatric care.

2. **Confidentiality**

I understand that all information shared during sessions is kept confidential, except in the following situations:

- If I express intent to harm myself or someone else.
- If there is suspected abuse or neglect of a child or vulnerable adult.
- If records are subpoenaed by a court of law.
- If I give written consent through a signed Release of Information (ROI).

Outside of these exceptions, my information will not be shared with anyone without my permission.

3. **Telehealth Agreement**

I understand that services may be provided through video call, phone, or in person (if available). I agree to participate in services through the method I am most comfortable with.

Preferred platform (Zoom, Teams, FaceTime, phone call, etc.): 

What is your preferred platform?

4. **Scope of Services**

I understand that Stay and Talk offers non-clinical support services free of charge. Services are intended to provide emotional support, addiction counseling, and guidance. No mental health diagnoses or medication management will be provided.

5. **Eligibility**

I confirm that I am 18 years or older.

6. **Voluntary Participation**

I understand that I can pause or stop services at any time, and I may request to end services for any reason, without penalty.

7. **Digital Signature**

By typing my name below, I acknowledge that I have read and understood the above information and voluntarily consent to services provided by Tyler Zenz, MA, LAC.

Full Name (Typed Signature): 

Date: