Consent form | My Site 2

Consent Form

Please fill out the following form.

First name

Last name

Address

Phone

Date of birth

Month

Day

Year

Consent to treatment: I have read and understood the below information, and any questions that I had have been answered. I agree to freely consent to receive psychological and case management services.

Yes

Mutual rights and responsibilities: The relationship must remain limited to a respectful therapeutic framework. You may refuse any therapeutic suggestions offered to you, or to suspend or cease treatment at any time without penalty. If you decide to stop treatment for any reason, please notify your therapist so that your file can be closed and/or you can be referred to another resource. If you stop treatment without an explanation, your file will automatically be closed after 30 days.

Do you give consent to receive emails, texts and phone calls?

Yes

Do you give consent to receive services such as assessment, therapy, counselor, skills and development training, medication management, wraparound & targeted case management, telehealth and coping skills?

Yes

Initials

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