Consent to Treat

Parent/Guardian Name
First Last
1. Client Name
First Last
Date of Birth
MM slash DD slash YYYY
Age
2. Client Name
First Last
Date of Birth
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
MM slash DD slash YYYY
Parent / Guardian Signature
Date
MM slash DD slash YYYY
Witness Signature/Title (For Office Use Only)
Date
MM slash DD slash YYYY