This form is to document that I give my permission and consent to therapist and the other employees/contractors of PhoenixWay to Holistic Natural Health, to provide treatment to me. I understand that because of the counseling or therapy, I may experience emotional strains, feel worse during treatment temporarily, and make life changes that could be distressing.

I understand that this therapist does not provide an emergency service, and I have been informed of whom to call in emergency or during weekend and evening hours.  [Guilford-Randoph County residents should call Trillium Health Resources MCO @ 888-302-0738.  Davidson-Forsyth-Rockingham County residents should call Vaya Partners MCO @ 800-962-9003.]  For severe psychiatric and medical emergencies, I understand I should call 911.

I understand that regular attendance will produce the maximum benefits but I am free to discontinue treatment at any time. If I decide to do so I will notify the therapist at least two weeks in advance so that effective planning for continued care can be implemented.

I understand that conversations with the therapist will almost always be confidential with the exception of situations involving immediate harm to myself or others or when subpoenaed by a court of law. The therapist has a legal responsibility to protect anyone I may threaten with violence, harmful or dangerous actions (including those to myself) and may break confidentially of communication if such a situation arises. I understand that the therapist will make reasonable efforts to resolve these situations before breaking confidentiality. I further understand that therapist, by law, must report actual or suspected child or elder abuse to the appropriate authorities.

I know of no reason that I should not undertake this therapy and I agree to participate fully and voluntarily. I have read and understood the following forms and that I agree to abide by their terms during our professional relationship:

1. Consent for Treatment

2. Financial Agreement

3. Professional Disclosure Statement

4. HIPAA Notice

5. Authorizations for Disclosure (optional)

6. Private Membership Association Agreement (private pay only)