Consent for Additional or Transfer of Care
Please review and complete this form to acknowledge and consent to the transfer of your therapeutic care within Choosing Change Counseling.
Purpose
This form is to document your acknowledgment and consent to transfer your therapeutic care to another clinician within Choosing Change Counseling. Reasons for transfer include scheduling availability, a change in your treatment needs, adjunct treatment with an additional clinician, or at your request.
Transfer Details
Your care is being transferred to another contracted therapist within Choosing Change Counseling. The receiving clinician will have access to relevant clinical information necessary to provide you with continuity of care.
Client Name
*
Current Therapist
*
Receiving Therapist
*
I am consenting to have my therapeutic care transferred to another clinician within Choosing Change Counseling.
Yes
Relevant clinical records and treatment history may be shared with the receiving clinician to support continuity of care.
Yes
I may ask questions about this transfer at any time and am encouraged to discuss any concerns with my current or incoming clinician.
Yes
This consent is specific to the transfer of care within Choosing Change Counseling and does not authorize the release of records to any outside party.
Yes
I understand that even if my original clinician is still contracted by Choosing Change Counseling, I may not be able to transfer back to them.
Yes
I understand that clinician transfers are based on clinical need and therapist availability.
Yes
Client Acknowledgment & Consent
I have read and understood the information above. I voluntarily consent to the transfer.
I have read and understood the information above. I voluntarily consent to the transfer.
Client Signature
*
Date
*
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Month
-
Day
Year
Date
Submit Consent
Submit Consent
Should be Empty: