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Patient First Name*
Patient Last Name*
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Patient Phone Number *
Date of Birth*
The temporary audio capture is used solely for creating clinical notes to ensure detailed and accurate documentation of your care.
The audio recordings are not stored or shared and are automatically deleted after the notes are generated.
All information is handled with strict confidentiality and in full compliance with applicable privacy laws.
This process is designed to improve the quality of care without compromising your privacy.
By signing below, you acknowledge that you have read and understand this consent form and agree to the use of secure AI-based charting technology during your sessions.
If you have any questions or concerns, please feel free to discuss them with your provider before signing. You also have the option to cancel or decline the use of the technology at the start of your appointment by informing your provider.
Signature & Date* Today's Date*
By submitting, you agree to receive text messages at the provided number from IShine Behavioral Health. Message frequency varies, and standard message and data rates may apply. You have the right to OPT-OUT receiving messages at any time. To OPT-OUT, reply "STOP" to any text message you receive from us. Reply HELP for assistance.