Select Provider:* Select Provider Bailey, Kristy, LPE-I Bockleman, Mallory, LPC Cavell, Timothy, Ph.D Crouch, Robert, LPE Gheen, Sarah, LPC Gray, Kelly, LCSW Hill, Nicole, LPC Hussey, Jonna, LCSW Jordan, Kathy, LCSW Lankford, Chris, LCSW Mendenhall, Anna, LCSW McCray, Kristen, LCSW Meeker, Leslie, LPC Meeks, Kamie, LCSW Naples, Steffanie, LMSW Reed, Carrie, LPC Rievert, Katie, LMSW Saragusa, Sarah, LPC Sawyer, Caroline, LCSW Shackelford, Susan, Ph.D Shields, Chuck, LPC Strickland, Matthew, LPC Sundara, Kelsey, LCSW
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INFORMED CONSENT TO TREAT I understand there are risks, varying lengths and methods of treatment, as well as possible consequences of the decided treatment which typically includes, some, or many of the following methods and interventions: Stabilization, Decrease and relieve symptomatology, Improve coping, Skill development, Grief resolution, Stress management, Behavior modification, Medication management
1. While I expect benefits from this treatment I fully understand and accept that because of factors beyond ourcontrol, such benefits and desired outcomes cannot be guaranteed.
2. I understand that this mental health provider does not provide emergency service and I will be informed of whom/where to call in an emergency or during the evening or weekend hours.
3. I understand that regular attendance will produce the maximum possible benefits but that I am free to discontinue treatment at any time in accordance with office policies.
4. I understand that I am financially responsible for any portion of the fees not covered or reimbursed by my health insurance.
5. I have been informed and understand the limits of confidentiality, that by law, the therapist must report to appropriate authorities any suspected child abuse or serious threat of harm to myself or another person.
6. I am not aware of any reason why I should not proceed with therapy/treatment and I agree to participate fully and voluntarily.
7. If applicable, I am the custodial parent of a minor child. I hereby give the non-custodial parent, permission to seek treatment on our child’s behalf. The provider practices with an association of independently practicing professionals which share certain expenses and administrative functions under the name PCA Resources, Inc. While they share office space, this provider is a completely independent professional rendering clinical services and is fully responsible for those services. Clinical records are separately maintained and other professionals cannot have access to them without your specific written permission. If you have any questions regarding this policy, please discuss these with the provider as soon as possible. Your signature below indicates consent for psychological/psychiatric treatment and indicates that you have read the above statement and agree to the above terms. Your commitment to this process and your assistance in understanding these necessary policies are an important part of your care.