CONSENT FOR TREATMENT FORM
Please complete the SECURE on-line form below.
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
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