Online Counselling

  TherapeuticVillage, LLC​

"Mental Health, Substance Abuse, Relationship and Parenting Solutions"

(859) 595-5860

Primary Office Location:  19 Wainscott Avenue, Winchester KY    

Copyright 2013. Therapeutic Village. LLC. All rights reserved.

GENERAL CONSENT  & PERMISSION TO TREAT FORM

​(For Online Therapy Only)


Before starting Therapy, please your enter name and email and then enter a Check Mark to indicate that you have Read, Understand and Consent to each item.    Then submit this form which will be sent as an email to TR Village who will forward to your therapist.    Once Submitted, this indicates that you have signed the form electronically.   You also attest that you are being truthful about your name and email address so that you personally have "electronically signed" the form by submitting it.