Consent For Treatment
Your signature below confirms that:
- You seek treatment with ___therapist's name___until such time as treatment goals are met or other reasons for termination of services have been specified.
- You have received, read, understood and accepted all the information contained in the ___agency/practice name___ Office Policies and Information, the Professional Disclosure Statement, the Client Rights and Procedure to File a Complaint information, and the Consent for Treatment.
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Client Signature and Date
If more than one individual (e.g. couple or family) seeks therapy, please have each of the others sign below. Their signature indicates they have also read the Office Policies and Information and the Professional Disclosure Statement and Consent for Treatment. Additional copies of these will be provided upon request.
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Client Signature (2)
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Client Signature (3)
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Client Signature (4)
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Client Signature (5)
