ACKNOWLEDGEMENT AND CONSENT

ACKNOWLEDGEMENT AND CONSENT
CLIENT NAME
MR#
I have read and understand the Contract for Outpatient Services. At any point in my therapy experience at Delta Psychological & Neurobehavioral Services I may ask for clarification of any point in the Contract by talking with my therapist or Clinical Director.

HIPAA Notice of Privacy Practices

I acknowledge receipt of the HIPAA Notice of Privacy Practices.

I have had my financial responsibilities explained to me and I accept these responsibilities as noted on my Financial Agreement.

I hereby give my consent to participate in services from Delta Psychological & Neurobehavioral Services. I understand that this consent applies to the duration of my treatment, but can be withdrawn at any time.
Client Signature*

Clear
Date

MonthDayYear
Date
Witness
Date

MonthDayYear
Date
If the client is a minor child:
Parent/Guardian Signature

Clear
Date

MonthDayYear
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Print Name
Relationship to child
My signature indicates that I have the legal authority to consent to treatment for this child.
Others who also have this legal authority:
Witness
Date

MonthDayYear
Date
Should be Empty: