I do hereby seek and consent to take part in the treatment by a designated therapist from Brightside Family Services. I understand that developing a treatment plan with this therapist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in the 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 am aware that I may stop my treatment with this therapist at any time. I understand that I will still be responsible for paying for all services previously rendered. I understand that even if I am mandated to attend therapy, services with this particular provider are voluntary, and I can seek services elsewhere to meet my obligations.
I know that I must call my therapist to cancel an appointment at least 24 hours before the time of the appointment. If I fail to do so, I will be charged for that appointment.
I am aware that if my insurance is being billed for these services, 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 I am responsible for notifying the therapist of any changes to my insurance. I also understand that I am responsible to pay for services I have received if my insurance company denies the claim.
My signature below shows that I understand and agree with all of these statements.