Consent to Treat Parent/Guardian Name First Last 1. Client Name First Last Date of Birth Date Format: MM slash DD slash YYYY Age2. Client Name First Last Date of Birth Date Format: MM slash DD slash YYYY AgePhone (Home)Phone (Cell)Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Permission to leave a message on home, cell or by text.* Yes NoNewsletter* Yes NoEmail 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 Date Format: MM slash DD slash YYYY Parent / Guardian SignatureDate Date Format: MM slash DD slash YYYY Witness Signature/Title (For Office Use Only)Date Date Format: MM slash DD slash YYYY