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    Consent For Treatment

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    jirehcounseling
    This document summarizes the consent to treatment agreement between a client and therapist/treatment team. It states that the client consents to receiving treatment, will work actively with their therapist to develop and track progress on treatment goals, and may stop treatment at any time. It also notes that insurance or other third parties may be provided information about treatment costs and providers. The client signs to acknowledge understanding and agreeing to these terms.

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    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd

    Consent For Treatment

    Uploaded by

    jirehcounseling
    48 views1 page
    This document summarizes the consent to treatment agreement between a client and therapist/treatment team. It states that the client consents to receiving treatment, will work actively with their therapist to develop and track progress on treatment goals, and may stop treatment at any time. It also notes that insurance or other third parties may be provided information about treatment costs and providers. The client signs to acknowledge understanding and agreeing to these terms.

    Original Title

    consent for treatment[1]

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    This document summarizes the consent to treatment agreement between a client and therapist/treatment team. It states that the client consents to receiving treatment, will work actively with their therapist to develop and track progress on treatment goals, and may stop treatment at any time. It also notes that insurance or other third parties may be provided information about treatment costs and providers. The client signs to acknowledge understanding and agreeing to these terms.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    48 views1 page

    Consent For Treatment

    Uploaded by

    jirehcounseling
    This document summarizes the consent to treatment agreement between a client and therapist/treatment team. It states that the client consents to receiving treatment, will work actively with their therapist to develop and track progress on treatment goals, and may stop treatment at any time. It also notes that insurance or other third parties may be provided information about treatment costs and providers. The client signs to acknowledge understanding and agreeing to these terms.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 1

    Consent to Treatment

    I do hereby seek and consent to take part in the treatment provided by this agency. I
    understand that developing a treatment plan with this therapist/team and regularly
    reviewing our work toward 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/team.

    I am aware that I (or my child) may stop treatment with this therapist/team at any time. I
    understand that I may lose other services or may have to deal with other problems if I
    stop treatment. (For example, if my treatment has been court-ordered, I will have to
    answer to the court.) I know that I must call to cancel an appointment at least 24 hours
    before the time of the appointment or as soon as reasonably possible.

    I am aware that an agent of my insurance company or other third-party may be given


    information about the type (s), cost (s), and providers of any services I receive.

    My signature below shows that I understand and agree with all of these statements.

    ___________________________________ _______________
    Print Name of Consumer Date

    ___________________________________ _______________
    Signature of Consumer Date
    (or person acting for consumer)

    ______________________________________
    Relationship of Person Acting for Consumer

    I, the therapist, have discussed the issues above with the consumer/family (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(s) is not fully competent to
    give informed and willing consent.

    __________________________________ ________________
    Signature/Title/Credentials Date

    CR101—Consent to Treatment Est. Mar 08

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