Thomas Park, M.D. & Associates23077 Greenfield Rd. Suite 430Southfield, MI 48075Phone: (248) 552-0044Fax: (248) 423-7777
I understand that as a patient at Thomas Park, M.D., P.C. & Associates, I may receive a range of services. The type and extent of services that I will receive will be determined following an initial assessment and thorough discussion with me. The goal of the assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the course of several months.
I understand that all information shared with the clinicians at Thomas Park, M.D., P.C. & Associates is confidential and no information will be released without my consent. Consent to release information is through written authorization. Verbal consent for limited release of information may be necessary under special circumstances. I further understand that there are specific and limited exceptions to this confidentiality which include the following:
I understand that a range of professionals provide services at Thomas Park, M.D., P.C. & Associates.
I understand that if receiving medications, while they may provide significant benefits, they may also pose risks. Psychotherapy may elicit uncomfortable thoughts and feelings, or may lead to the recall of troubling memories and may have unwanted side effects.
If I have any questions regarding this consent form about services at Thomas Park, M.D. & Associates, I may discuss them with my therapist or physician. I have read and understand the above. I consent to participate in the evaluation and treatment offered to me by Thomas Park, M.D. & Associates. I understand that I may stop treatment at any time.
I am a patient at Thomas Park, M.D. & Associates. Before I sign this form, I talked to my doctor. I understand: