23 May 17 Informed Consent Fee agreement and disclosures

Disclosure Statement & Agreement for Services
Introduction
you know that I utilize a "No Secrets Policy" when
your family. Please feel free to ask me more about my "No Secrets Policy" and how it may apply
parents and other guardians who provide authorization for their child's
Treatment alternatives may include, among other possibilities, referral, changing your treatment plan or terminating your therapy. Your signature indicates that you have read this agreement for services carefully and understand its contents. Please ask me to address any questions or concerns that you may
Name of Patient
have about this information before you sign.
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