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 I understand that this consent applies to the duration of my treatment, but can be withdrawn at any time.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

Month Day Year
Date
Witness
Date

Month Day Year
Date
If the client is a minor child:
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
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

Month Day Year
Date
Should be Empty: