Psychotherapy Verification Release Form

Psychotherapy Verification Release Form

To be filled out by the student.
The Seattle School Psychotherapy Requirement Policy can be found on the website at www.theseattleschool.edu/students/catalog under "Forms."
Student Name*

First NameLast Name
Student Email*
example@example.com
I am a student enrolled in The Seattle School of Theology & Psychology's ("The Seattle School") Counseling Psychology Master's Degree program ("Program")*

Yes
Acknowledgement and Release
I have received, read and understand The Seattle School Psychotherapy Requirement Policy (Rev. 10/2021) (“Policy”). I understand and acknowledge the risks involved in psychotherapy, including, but not limited to, recalling, discussing and experiencing difficult, unpleasant, unwelcome, painful or embarrassing thoughts, issues, experiences and memories. I also understand and acknowledge that psychotherapy may result in my uncovering or recovering unpleasant or painful memories that I have forgotten. I also understand and acknowledge that the therapist I select may not be effective in helping me address my issues or that psychotherapy may not be suitable for me. I understand and acknowledge that I may find that I end therapy in a worse state than when I started.*

I agree
Release and Indemnification
I hereby release and agree to indemnify The Seattle School of Theology & Psychology and its directors, officers, faculty members, adjunct faculty members, employees, and agents (“Releasees”) from and against any and all claims, damages, injuries, losses, expenses and other liabilities arising from or in any way related to my psychotherapy, my therapist, the Policy or the Program (“Claims”), except for in those Claims caused entirely by the gross negligence or willful misconduct of The Seattle School or the Releasee seeking the benefit of this release of claims and agreement to indemnify.*

I agree
Please ensure you have read this information carefully before signing. This document contains a release of claims and indemnification agreement.
Signature*

Clear
Should be Empty:

Psychotherapy Verification Release Form

Acknowledgement and Release

Release and Indemnification