My signature below indicates that I have read and acknowledged all the information presented to me in this disclosure statement.
I understand its content and agree to abide by these terms during our professional relationship.
I understand I have the right to:
- Be informed of and participate in the selection of treatment modalities.
- Receive a copy of this consent.
- Withdraw this consent at any time.
If the client is under the age of 18 or unable to consent to treatment, I attest that I have legal custody of this individual and am authorized to initiate and consent to treatment on behalf of this.
I have been assured that strict adherence to professionalism and confidentiality will be observed.