Consent for Treatment/ Form

Clients Full Name

I understand that I must make and keep all appointments and that if I do not show up or cancel within 24 hours of the appointment I will be charg

I understand that my therapist is

I understand that my Doctor is

I have been informed of the treatment process, possible risks and benefits

I understand my privacy rights

I understand that each provider (therapist/doctor) may provide different types of treatment options and specialties and have made an informed decision about whom I will see.

I agree to follow my treatment plan including any family/group sessions recommended by my therapist/doctor

I understand treatment is an interactive process and that I must work with my therapist/doctor in order to get the most out of treatment

I understand I have the right to be treated with respect and dignity by all staff members at all times

I understand the grievance process

I understand that the treatment providers may have various levels of licensure, experience and training and have been informed of my provider's credentials

Sign Here by typing your name