VOCAT / Anglicare Victims Assistance Program Session Attendance Form

In order for us to claim for your VOCAT / Anglicare Victims Assistance Program session, we must get your written confirmation of your attendance. When using Telehealth (phone and/or video conference) this confirmation can be provided through completing this form.

Name of person completing form (required)
First Name Last Name

Email so you get a copy of this form (required) If you don't have one, you can use a trusted person's email

Relationship to Patient/Client (required)
SelfParent / GuardianPartnerFamilyFriend

Details of the telehealth session to be claimed through VOCAT / Anglicare Victims Assistance Program

Name of Patient / Client (required)
First Name Last Name

My psychologist / provider is (required)
Eryn BroughtonCandice BowersJeff Broughton

Telehealth session time and date (required) (in YYYY-MM-DD format (e.g. 2013-04-08))
Date: Time: Hour Minute AMPM

I confirm the above information is true and correct.
I confirm I (and/or the above mentioned client) attended the above session.

Signature (required)