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Consent to Treatment

I acknowledge that I have received, have read (or have had read to me), and understand the “Information for Clients” handout and/or other information about the therapy I am considering. I have had all my questions answered fully.

I do hereby seek and consent to take part in the treatment by the therapist named below. I understand that developing a treatment plan with this therapist and regularly reviewing our work toward meeting the treatment goals are in my and or my child’s best interest. I agree to play an active role in this process.

I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist. I understand that being in treatment may impact outcomes of any legal case that may be related to the focus of treatment. I understand that it is my responsibility to consult with my attorney about these issues, and then to make my own decision about whether or not to proceed with treatment.

I am aware that I may stop my treatment with this therapist at any time. I understand I will still be responsible for payment of services I have already received. I understand that I may lose other services or may have to deal with other consequences for me or my child if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.)

I know that I must call to cancel an appointment no less than 24 hours before the time of the appointment. If I do not cancel and do not show up, I will be charged for that appointment.

I am aware that an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive. I understand that if payment for the services I receive here is not made, the therapist may stop my treatment.

I am aware that non-identifying information about me may be used for quality assurance, treatment evaluation, and other service monitoring and/or research purposes.

By clicking the Read and Agree button, I certify that I understand and agree with all of the statements outlined in the Consent to Treatment.