Section 1: Client Information *

The following information is for the client that will receive the service from Ease of Mind.

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

This will be the number Ease of Mind will use for contact.

(###)

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Preferred Service Method for Contacting Client *

Phone Call

SMS (Text Messaging)

Preferred Time of Contact *

Morning (8am-12pm)

Afternoon (12pm-5pm)

Evening (5pm-8pm)

No Preference

Wellness Check-In Service *

$25 Connect At Any Time (pay-as-you-go)

$166 Daily Connect (1 connection per day for 1 week)

$100 Weekly Connect (1 connection per week for 4 weeks)

$285 Annual Connection (1 connection per month for 12 months)

Preferred Days for Contact *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

No Preference

Preferred Date to Begin Wellness Check-In *

MM

DD

YYYY

Emergency Contact Information *

The following information will be used as clients emergency contact

First Name

Last Name

Phone *

(###)

###

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Consent to Participate in Wellness Check-In *

Please read the Terms and Conditions and Privacy Policy before continuing.

I consent to, or can confirm that I have obtained informed verbal consent from the client to participate in the wellness check services provided by Ease of Mind. I understand and/or accept responsibility for ensuring the client is fully aware of the service, how their personal information will be used, and that they have voluntarily agreed to participate.

I agree to the collection, use, and storage of personal information as outlined in the Privacy Policy, and I understand that this information will be used solely for the purpose of conducting wellness check-ins.

I acknowledge that I understand and accept the terms and conditions of the wellness check-in service and the limitations, including that Ease of Mind is not a crisis intervention service.

I take full legal responsibility for ensuring that the client’s verbal consent is valid throughout the duration of the service and understand that I am accountable for any issues arising from the lack of written consent.

Full Name of Purchaser *

By entering my full name, I acknowledge that I agree to the terms and responsibilities outlined in this form.

First Name

Last Name

Phone *

(###)

###

####

Date *

MM

DD

YYYY