Notice Regarding
Information Submission and Communications

By submitting this form to Bella Stella Community, I acknowledge and agree that the completion of this form does not establish a doctor-patient or client-provider relationship. This form is intended solely to provide Bella Stella Community with preliminary information to assess whether I may be a potential candidate for services.

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I further understand that I may receive future communications from Bella Stella Community via electronic means, including but not limited to emails and text messages. These communications may or may not be protected under the Health Insurance Portability and Accountability Act (HIPAA), as well as applicable California state and local privacy laws.

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I acknowledge that electronic communication carries certain risks, including but not limited to unauthorized access or disclosure of personal information. Despite these risks, I consent to receive communications from Bella Stella Community through these channels, whether or not I ultimately engage in services with the organization.