Associate Marriage and Family Therapist Disclosure

Associate Marriage and Family Therapist Disclosure
As an Associate Marriage and Family Therapist, Patricia Rupe is currently employed by Beautiful Minds Medical, Inc. and supervised by Dr. K'dee Crews, licence# PSY32513. In order to ensure the highest standard of care, supervisors meet with their associates weekly and review the progress of their work. If you have any questions about this supervisory relationship, please contact Dr. Crews at (530) 889-8780. Signing this form acknowledges your informed consent for treatment by an Associate Marriage and Family Therapist under clinical supervision. Patricia is available for consultation upon your request.
I,
Client's name
,have read and fully understand this consent for treatment and office policies form, and voluntarily agree to undergo psychotherapy with Patricia. I also acknowledge that it is my responsibility to pay for services rendered to me by Patricia. I understand the limits of confidentiality and office policies regarding fee payment and cancellations.
Name*

First NameLast Name
Date*
Patient's Signature*

Clear
The patient understood and freely agreed to the terms listed above.
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