I authorize You First Health and Wellness Services LLC to contact the above-named person in case of an emergency.

Authorizations and Agreements with You First Health and Wellness Services LLC. Please read carefully and sign. The paragraphs below contain several agreements.

I understand and agree that I am responsible for the fees to You First Health and Wellness Services LLC before services are rendered.

I, (Print Name) hereby authorize You First Health and Wellness Services LLC

I may revoke this authorization at any time except to the extent that action has been taken in reliance upon it. If I do not revoke this authorization, it will expire one (1) year after I have terminated treatment.

(name of patient), agree and consent to participate in behavioral healthcare services offered and provided by You First Health and Wellness Services LLC, a behavioral health care provider. I understand that I am consenting and agreeing only to those services that the above-named provider is qualified to provide within: (1) the scope of the provider's license, certification, and training; or (2) within scope of license, certification, and training of the behavioral health care provider directly supervising the services received by the patient.