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 Sandhills MCO @ 800-256-2452.  Davidson-Forsyth-Rockingham County residents should call Cardinal MCO @ 800-939-5911.]  For severe psychiatric and medical emergencies, I understand I should call 911.

I understand that regular attendance will produce the maximum benefits, and I or 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 understand that though PhoenixWay generally encourages holistic and natural treatments, I might be suggested to visit a licensed psychiatrist for an assessment. My consent to do so remains my decision.

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 (to be read and signed)
2. Financial Agreement (to be read and signed)
3. Professional Disclosure Statement (to be read and signed)
4. HIPAA Notice (to be read only)
5. Authorizations for Disclosure (optional, only if communication by PhoenixWay with other individuals/agencies is desired)

By typing my full printed name and date in the boxes below, I hereby consent to the terms of this document.