Consent to Counseling. Once you sign this Agreement, you become a client at CFC, and you are consenting to enter into a counseling relationship with your therapist at CFC. You may revoke this Agreement in writing or terminate counseling at any time. Revocation of the Agreement terminates the relationship between you and CFC, but will not affect any action CFC has already taken based on the previous Agreement. Terminating the Agreement also does not prevent CFC from pursuing collection of fees you owe to CFC for services previously delivered. If you are not benefiting from counseling, or if your therapist and you have failed to establish a positive working relationship, your therapist may provide you with one or more referrals to other therapists who may better serve your needs.
Consent to Counseling. Your signature below indicates that you have read this Agreement and agree to its terms. Client Name Client Signature Date Date Schedule of Fees This document outlines the schedule of fees, and must be agreed to by the client, and by Xxxxx Xxxxxxxx Good, hereafter referred to as the Therapist.
Consent to Counseling. Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms. Signature of Client Printed Name
Consent to Counseling. The process of growth and change that occurs in therapy may sometimes include emotional pain, unpleasant memories, and periods of temporary impasse. To the best of my ability, I agree to openly discuss such issues with therapist(s) at LNFT. LNFT reserves the right to discontinue care and provide appropriate referral options on a case-by-case basis. If at any point I feel that I have been harmed or mistreated, and efforts to discuss this with my therapist are unsatisfactory, I may contact North Carolina Social Work Board regarding LCSW clinicians, North Carolina Psychology Board regarding PsyD clinicians, or North Carolina Board of Licensed Professional Counselors for LPC clinicians for appropriate grievance procedures. SIGNATURE OF CLIENT DATE SIGNATURE OF PARENT, GUARDIAN, OR PERSONAL REPRESENTATIVE DATE
Consent to Counseling. The process of growth and change that occurs in therapy may sometimes include emotional pain, unpleasant memories, and periods of temporary impasse. To the best of my ability, I agree to openly discuss such issues with therapist(s) at LNFT. LNFT reserves the right to discontinue care and provide appropriate referral options on a case-by-case basis. If at any point I feel that I have been harmed or mistreated, and efforts to discuss this with my therapist are unsatisfactory, I may contact North Carolina Social Work Board regarding LCSW clinicians or North Carolina Board of Licensed Clinical Mental Health Counselors for LCMHC clinicians for appropriate grievance procedures. SIGNATURE OF CLIENT DATE SIGNATURE OF PARENT, GUARDIAN, OR PERSONAL REPRESENTATIVE DATE
