Consent Forms

CONSENT FORMS
Custody Consent Form
This form is required prior to your first appointment. Each custodial parent/guardian must sign and submit this form.
Custody Consent Form
Zoom for Healthcare Consent and Collaboration
This form is required prior to your first Zoom for Healthcare appointment.
Zoom for Healthcare Consent Form
Assessment and/or Treatment Consent Form
This form is required prior to beginning your assessment and/or treatment.
Assessment and/or Treatment Consent Form
Triage and Medication Adjustment Agreement
This form is required prior to your appointment with our Family Physician Team.
Triage and Medication Adjustment Agreement
Consent to Share Information Form
This form is required if you wish to share information between the Possibilities Clinic and another institution.
Consent to Share Information Form
Credit Card Authorization Form
This form is required if you wish to give permission to charge your regular sessions automatically.
Credit Card Authorization Form
Disability Tax Credit Certificate (DTCC) Agreement and Understanding
Disability Tax Credit Certificate (DTCC) Agreement and Understanding
COVID-19 Liability Waiver
This form should be filled out if requested by the clinic. You must be a registered patient with the clinic and have an upcoming appointment scheduled.
COVID-19 Liability Waiver
COVID-19 Patient Screening Checklist
This form should be filled out if requested by the clinic. You must be a registered patient with the clinic and have an upcoming appointment scheduled.
COVID-19 Patient Screening Checklist