Consent to Treat Parent/Guardian Name First Last 1. Client Name First Last Date of Birth MM slash DD slash YYYY Age2. Client Name First Last Date of Birth MM slash DD slash YYYY AgePhone (Home)Phone (Cell)Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Permission to leave a message on home, cell or by text.* Yes No Newsletter* Yes No Email Emergency Contact NamePhoneI understand that the treatment offered by CenterPoint Counseling and Consulting is of a voluntary nature. I hereby consent to the diagnostic and treatment procedures suggested by the licensed clinician, given the symptoms I have shared. I do so with the understanding that I have the right to accept or reject any and/or all treatment plans that are presented to me.Signature of Consent: My/our signatures below indicate our Consent To Treat.Client Signature (If over 14 years of age) Both Signatures are needed for couples counseling.Date MM slash DD slash YYYY Parent / Guardian SignatureDate MM slash DD slash YYYY Witness Signature/Title (For Office Use Only)Date MM slash DD slash YYYY
