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Student, Intern, and Volunteer Form – Behavioral Health

  • NATIVE HEALTH, through the Medical, Dental, Behavioral Health (BH) and/or WIC Clinics, provides educational opportunities for Students, Interns and Volunteers (S/IN) from various educational institutions. As appropriate, we may include a Student/Intern or Volunteer to join our licensed providers in the provision of the intake, examination and/or service/treatment process. If you agree to include S/IN in your treatment process, we must have your consent.

    Please read the following and feel free to ask any questions. If you give your consent, please sign at the bottom. Our intent is to give you the highest quality care possible. I understand that Students, Interns and Volunteers are an important part of professional education and I consent to the following:

    I understand that Students, Interns and Volunteers are an important part of professional education and I consent to the following:
    • a. Patient/Client Intake
    • b. Supervised service/treatment process
    • c. Consultation

    • By signing the consent form it does not obligate the patient to any treatment. You have the option to revoke, IN WRITING, this consent at any time during the service/ treatment process. The original form will be filed in the patient chart and a copy provided to the patient or parent/guardian of the pediatric patient, if requested.

  • Provider & Clinic Signature.

    Staff Signature:
    Patient first name:
    email:
    Date:
    Patient last name:

    FOR MINORS (under age 18):

  • Patient/Guardian Signature

  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.