Counseling Agreement/disclosure Form Page 2
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2I understand that I may be referred to other services of the organization or another
agency or agencies as appropriate that may be able to assist with particular concerns
that have been identified. I understand that I am not obligated to use any of the
services offered to me.
I acknowledge that I have received a copy of the Combined Privacy Act Notice and
Tennessen Warning. If you choose to not sign or verbally acknowledge the Combined
Privacy Act Notice and Tennessen Warning, your counselor may not provide NFMC
Program or MHA Project services.
Dakota County CDA
I acknowledge that ______________________, NeighborWorks America, and Treasury
may conduct follow-up with me related to program evaluation.
Dakota County CDA
Please check here if you do not want to be contacted by __________________,
NeighborWorks America and Treasury for program evaluation purposes only. By
checking this box you are only opting out of being contacted for program
evaluation.
Client must sign if information was provided by face-to-face counseling session.
Print Name of Client
Client’s Signature
Date
Print Name of Client
Client’s Signature
Date
Verbal Authorization is permissible if information was provided to client by non
face-to-face counseling session.
The undersigned verifies that the client was fully informed of the information contained
herein and understood its nature. The client has given verbal authorization and
acknowledgement. A copy of this notice with counselor’s signature has been mailed to
the client.
Client’s Name
Date
Counselor’s Signature
Note to Counselor:
If the client chooses not to sign this form or provide verbal authorization, the
Counselor may not provide NFMC Program or MHA Project services.
NFMC/MHA Foreclosure Mitigation Counseling Agreement/
Disclosure Form
2
05/01/2013
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