Consent for Treatment|
I 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
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:
State licensure regulations may require my therapist or service provider to receive ongoing supervision
Accredition organizations, as well as insurance companies, may require that my treatment plan be reviewe
The standards of care which guide most mental health professional recommend that supervision and/or consultation
be obtained in high risk situations such as threats and/or acts of harm to self or others
Other special circumstances, such as preparation to testify in court
The right to be treated with dignity and respect by all staff
The right to be involved in the planning and/or revision of my treatment plan
The right to know about my treatment progress or lack thereof
The right to reject the use of any therapeutic technique, and to ask questions at any time abou the methods used
The right to be spoken to in a language that is fully understood
The right to a clean and safe environment
The right to refuse to be video taped, audio recorded, or photographed
The right to end treatment at any time unless court ordered
The right to file a complaint or grievance about the agency or staff
The right to confidentialityof clinical records and personal information according to federal and state laws
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