Perspectives Counseling and Consultation    ~     Tammy Greene, MA, LMHC

Consent to Treatment 

With enough knowledge, and without being forced, I enter into treatment with this therapist. I will keep my therapist fully up to date about any changes in my feelings, thoughts, and behaviors. I expect us to work together on any difficulties that occur, and to work them out in my long-term best interest. 

I acknowledge that I have received, have read (or have had read to me), and understand the “Information for Clients” booklet available to me in the waiting room area and/or other information about the therapy I am considering. I have had all my questions answered fully. 

I do hereby seek and consent to take part in the treatment by the therapist named below. I understand that developing a treatment plan with this therapist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. 

I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist. If at any time, I am not satisfied by our progress towards goals, I will communicate this to my therapist and allow the opportunity to process this and alter our current treatment methods before choosing to end treatment.  I recognize that if I feel it is in my best interest to stop treatment, I may do so at any time.  However, it is best to provide this therapist with at least 7 days’ notice of my intentions and meet with the therapist for one last time. I am aware that, should I choose to stop treatment, the only thing I will still be responsible for is paying for the services I have already received.

I know that I must call to cancel an appointment at least 24 hours (1 day) before the time of the appointment. If I do not cancel and do not show up, I will be charged for that appointment. 

If I Choose to bill my health insurance, I am aware that an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive. I understand that if payment for the services I receive here is not made, the therapist may stop my treatment.
I know that it is MY RESPONSIBILITY, not my therapists, to keep track of how many sessions I have available to me to use through my insurance, and how many I have used. Should I go over the allotted number of sessions given by my insurance company, I am responsible for payment of those sessions in full at the hourly rate of treatment.  I also understand that I am responsible for all payments that my insurance company may deny payment on.

My signature below shows that I understand and agree with all of these statements. If the client is a minor, then I am agreeing that I am the legal custodian of this child, and there are no court orders in effect that would prohibit me from consenting to the treatment of this child.
My signature below means that I understand and agree with all of the points above.
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Signature of client (or guardian/parent) 								Date 

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Printed name 													Relationship to client (if necessary) 

I, the therapist, have discussed the issues above with the client (and/or his or her parent, guardian, or other representative). My observations of this person’s behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent. 

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Signature of therapist 											Date 
❑ Copy accepted by client   ❑ Copy kept by therapist 				This is a strictly confidential patient medical record.