Consent to Treat

Parent/Guardian Name
First Last
1. Client Name
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Age
2. Client Name
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Age
Phone (Home)
Phone (Cell)
Address
Street Address Address Line 2 City State ZIP Code
Permission to leave a message on home, cell or by text.*
- Yes
- No
Newsletter*
- Yes
- No
Email
Emergency Contact Name
Phone
I 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
Date Format: MM slash DD slash YYYY
Parent / Guardian Signature
Date
Date Format: MM slash DD slash YYYY
Witness Signature/Title (For Office Use Only)
Date
Date Format: MM slash DD slash YYYY