Consent for Treatment

I am requesting evaluation/treatment for at Kardia Counseling & Consulting, PLLC. If following evaluation, it is determined that further treatment is appropriate, I hereby, consent to treatment as deemed necessary.

While I expect benefits from this treatment, I fully understand that because of factors beyond our control or other factors, such benefits and particular outcomes cannot be guaranteed.

I understand that because of the counseling or therapy services, I may experience emotional strains, feel worse during treatment, and make life changes which could be distressing.

I understand that the clinician is not providing an emergency service, and I have been informed of whom to call if I am having an emergency or during weekend and evening hours.

I understand regular attendance will produce the maximum benefits yet I am free to discontinue treatment at any time. If I decide to do so, I will notify the clinician at least two weeks in advance so that effective planning for continued care can be implemented.

I understand that conversations with the clinician will almost always be confidential. I further understand that the clinician, by law, must report actual or suspected child or elder abuse to the appropriate authorities. In addition, the clinician has a legal responsibility to protect anyone that I may threaten with violence, harmful or dangerous actions (including those to myself) and may breach the confidentiality of our communications if such a situation arises. I understand that the therapist will make reasonable efforts to resolve these situations before breaching confidentiality.

I understand that I am financially responsible for this treatment and for any portion of the fees not reimbursed or covered by my health insurance.

I am unaware of any reasons I should not undertake this therapy. I fully and voluntarily agree to participate.

Patient Signature:
Patient Signature Date:
Parent/Legally Responsible Person:

(if patient is below 18 years of age)
Parent Signature Date: