I, the client/responsible party, acknowledge that I have received and reviewed the documents titled “Information for Therapy Clients” and “Client Confidentiality in Therapy.” I have discussed any points I did not understand, and I have had my questions, if any, fully answered. Ifatanytimeduringmy/my child’s treatment I have additional questions about any of the subjects discussed in these documents, I will bring them up to my/my child’s therapist, who will do his or her best to answer them.
I consent to enter myself/my child into treatment in the form of therapy sessions with the therapist whose name appears below. I understand that my signature below does not indicate that I am waiving any of my/my child’s rights. I will keep my therapist fully up to date about any changes in my/my child’s feelings, thoughts, and behaviors. I expect us to work together on any difficulties that occur and to work them out in my/my child’s long-term best interests.
I agree to pay for all services rendered to me/my child by this therapist, as outlined in the policies and procedures contained in the documents provided to me. I also agree to pay the missed session fee when I fail to give the notice required by the policies and procedures.
I understand that if I choose to use my/my child’s insurance benefits, I will remain fully responsible for this therapist’s fee; however, this therapist will bill my insurance and follow any other necessary administrative procedures, as agreed in his or her contract with my insurance company. For this purpose, I give permission for my/my child’s therapist to communicate with my insurance company about my/my child’s condition and treatment and to receive payment on my behalf.