if you don't have time to fill this out…
Prior to our first counseling session, I will need you to complete each of these 7 forms. After filling out the first form, you will be provided with the next form, until the last has been completed. This may take 15-30 minutes or more.

Form 2 of 7

Informed Consent for Treatment

02 – Informed Consent for Treatment
Informed Consent Process:

You will be provided with an explanation of your condition, the recommended interventions and the time frames for the interventions as well as the available treatment options.

All clinical information will be confidential with the exception of information pertaining to child and elderly abuse and information regarding injury to self or others. Children who are fourteen years old and older have confidentiality from parents, guardians and others. Clinical information will be released upon written consent by the client and discussion with the clinician.

Information pertaining to the potential benefits of treatment, the associated risks or potential side effects of any proposed interventions will be provided through counseling and or literature. Family members and/or other members of your support network will be included in the treatment and decision-making process only when you consent through written consent.

Credentials of the clinician are available throughout the treatment process.

Counseling will be conducted through in person (face to face) sessions, telephonic and other telemedicine secure platforms. Counselor and client must both agree on how the counseling will be conducted.

You have the right to refuse treatment and terminate counseling at any time. Treatment referrals and additional treatment resources will be made available to you.

You will be informed of all treatment fees. It is your responsibility to ensure that all agreed upon fees for services rendered are paid at the beginning of each counseling session.

I have reviewed this document and received adequate information regarding the informed consent process. I consent to treatment and will continue to participate in the decision-making process during my treatment.

Clinician’s Signature


Date Signed


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