Consent for Treatment Form
This is a free template you may use to create a Consent for Treatment Form for a variety of services including mental health, psychotherapy and medical care.
Consent for TreatmentI have chosen to receive mental health services in the form of [Service Name] for myself and/or my child from [Company Name]. My decision is voluntary and I understand that I may terminate these services at any time, unless my participation has been mandated by a court of law.
Nature of Mental Health Services
I understand that during the course of treatment I may need to discuss material of any upsetting nature in order to resolve my problems. I also understand it cannot be guaranteed that I will feel better after completion of treatment.
Compliance with treatment plan
I agree to participate in the development of an individualized treatment plan. I understnad that consistent attendance is essential to the success of my treatment. Frequent "no shows" and/or late cancellations may be grounds for termination of services, as well as failure to follow my treatment plan in any form.
I understand there are certain circumstances which may require [Company] provider(s) to receive supervision. These circumstances include, but are not limited to the following:
I understand I may reach my [Company] provider at [Phone Number]. If not available, I can leave a message and my call will be returned as soon as possible. If I have a life threatening emergency situation, I may call 911.
I have read, discussed and understood all of the above.
Signature / Date
Witness / Date