I voluntarily consent that I/my child will participate in an evaluation and/or treatment by staff from Lifestyle I understand that there may be risks and benefits associated with participating in or failing to participate in the evaluation and treatment.

I hereby authorize Lifestyle to communicate with me electronically via email, text message and telehealth platforms. I understand that this indicates that information regarding appointments, diagnosis, medication, information related to treatment, and other protected health information, will be transmitted, and is considered as part of my medical record. I understand that any information that I consider confidential, should be discussed during a scheduled session with my provider.