TRUE CONNECTIONS COUNSELING, PLLCConsent for Treatment • July 15th, 2019
This document/agreement contains important information about 1) our professional services, 2) summary information about the Health Insurance Portability and Accountability Act (HIPAA) and confidentiality, and 3) our business practices. Although a bit long and complex, it is important that you read it carefully and ask any questions you might have today or before our next session. Your clinician will give you a copy to take home. When you sign this document, it will represent an agreement between you and your clinician. However, you may revoke this agreement in writing at any time. That revocation will be binding unless a) your clinician has already taken action in reliance on it, b) has legal obligations imposed on it by a court of jurisdiction, or c) if you have not satisfied financial obligations you have incurred.
Consent for TreatmentConsent for Treatment • October 16th, 2014
This agreement is intended to provide with important information regarding the practices, policies, and procedures of Suzanne G. Gorter, MFT, and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Do not hesitate to discuss any questions or concerns that you have with the content of this agreement prior to signing.
New Dimensions Counseling, LLCConsent for Treatment • December 18th, 2021
At any time inquiries can be made regarding evaluation, treatment recommendations, or alternative treatment options. Information can be provided about the methods and techniques of therapy and the development of treatment goals. Additionally a client is entitled to receive information about the fee structure and may seek a second opinion fro another therapist or terminate the therapeutic relationship at any time. Sexual intimacy is never appropriate in a professional relationship and should be reported immediately. If the client is a child who is consenting to mental health services disclosure shall be made to the child. If the client is a child whose parent or legal guardian is consenting to mental health services, disclosure shall be made to the parent or legal guardian.
CONSENT FOR TREATMENTConsent for Treatment • May 20th, 2020
Permission for Diagnosis and Treatment - I hereby give consent to the authorities of The HSC Pediatric Center for such diagnostic procedures, treatment and therapeutic activities.
ContractConsent for Treatment • February 13th, 2021
CONSENT FOR TREATMENT I hereby agree to a physical therapy evaluation and routine treatment by a Massachusetts licensed physical therapist or under his/her supervision, a Massachusetts licensed physical therapy assistant. I understand that the physical therapy treatment will be provided for the identification, prevention, remediation, and rehabilitation of an acute or chronic physical dysfunction. I understand that my physical therapist/physical therapy assistant will have me involved at all times in the decisions of my care. My consent to any treatment set forth is voluntary and I may withdraw any such consent at any time and to any aspect of the prescribed treatment. I agree, or agree to have my child, receive routine physical therapy treatment as explained to me by the treating physical therapist.
ALBERTA PROFESSIONAL SERVICES, INC.Consent for Treatment • May 3rd, 2023
Consent - I (we) give consent for services to be provided by Alberta Professional Services as identified in my service plan - “Person Centered Plan (PCP)” or “Individual Service Plan (ISP).” I (we) have been informed of the benefits, potential risks, and possible alternative methods of treatment/habilitation. This consent will continue throughout the client’s admission to the service.
PATIENT AGREEMENTConsent for Treatment • November 12th, 2020
The patient understands that psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, especially during the first few weeks of treatment because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems.
CONSENT FOR TREATMENTConsent for Treatment • March 17th, 2021
INFORMED CONSENT: This contract explains the conditions that you, as the client, have agreed upon when obtaining services through Center for Psychological Wellness, Inc. (hereafter referred to as CPWI). Some of these rights and obligations are imposed by Florida law while others are established herein by contractual agreement. Any concerns regarding the matters stated herein should be discussed prior to initiation of treatment. I understand that my records are protected under the applicable state law governing healthcare information that relates to mental health services and under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records 42 DRF Part 2, and cannot be disclosed without my written consent unless otherwise provided for in state or federal regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it.
CONSENT FOR TREATMENT, RELEASES, ACKNOWLEDGEMENTS AND FINANCIAL AGREEMENT FORMConsent for Treatment • October 9th, 2008
Consent for TreatmentConsent for Treatment • April 10th, 2023
PATIENT AGREEMENTConsent for Treatment • August 10th, 2020
The patient understands that psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, especially during the first few weeks of treatment because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems.
POWDER RIVER ORTHOPEDICS & SPINE 508 STOCKTRAIL AVE, SUITE A GILLETTE, WY 82716Consent for Treatment • July 15th, 2020
Patient Name: Date of Birth:Consent for Treatment • March 26th, 2021
As either the patient or the legally authorized representative of the patient, receiving care at this facility, I make the following consents, understandings, and agreements on my own behalf and on behalf of the patient, in partial consideration of health care services to be provided to the patient at Mountain Peaks Family Practice.
Ken Goodman, LCSWConsent for Treatment • April 3rd, 2016
Consent for TreatmentConsent for Treatment • June 9th, 2018
I, , agree and consent to participate in health care services offered and provided by Oceanside Urology, LLC. If the patient is under the age of eighteen (18) or unable to consent to treatment, I attest that I have legal custody of the above named individual and I am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual.
Carlsbad, CA 92008Consent for Treatment • June 3rd, 2014
Whitling Counseling and Consulting 3201 State Route 257, Suite 1Consent for Treatment • May 12th, 2023
Welcome to Whitling Counseling and Consulting. This agreement provides those who seek treatment and/or consultation services with a clear understanding of how this private practice is managed. I hope this information will help you understand the nature of the services. This document is intended to provide you with enough information to make an informed consent to participate in treatment. Please read this carefully and do not hesitate to discuss your questions or concerns about this information with myself.
Consent for TreatmentConsent for Treatment • April 26th, 2019
By signing below, you are stating that you have read and understood this 2-page office policy statement and you have had your questions answered to your satisfaction. I accept, understand and agree to abide by the contents and terms of this agreement and further, consent to participate in evaluation and/or treatment. I understand that I may withdraw from treatment at any time.
Consent for Treatment/ Acknowledgment Agreement Signature FormConsent for Treatment • June 1st, 2021
Patients must give voluntary consent for mental health treatment. Your signature (or that of your legal guardian) will demonstrate consent for receiving mental health treatment from the Psychiatric Wellness Center. I voluntarily consent to mental health treatment as performed by the Psychiatric Wellness Center and its employees. This treatment may include but not limited to: assessment, screening, consultation and recommendations, psychotherapy, holistic services and psychiatric medication management. I understand that mental health treatment may involve certain risks and benefits and I understand these risks and benefits. I also understand the risks and benefits of declining treatment. I am also aware that I have the right to request information about alternative treatment options, should they exist. I have read the above information and I authorize the Psychiatric Wellness Center to provide mental health services to myself or this patient (if guardian).
Consent For TreatmentConsent for Treatment • March 30th, 2021
with important information regarding the practices, policies and procedures of Denise Williamson (Therapist). Any questions or concerns regarding the contents of this Agreement should be discussed with Denise Williamson prior to signing.
To our patients and families:Consent for Treatment • March 19th, 2020
Patients and families are essential participants in health care and we want you to understand your rights and responsibilities while receiving care from us. If you have any questions about this form, please ask your provider. If you are a parent/legally-authorized representative of a child, please read this agreement with the understanding that “I” and “me” means the child.
CONSENT FOR TREATMENT – AMBULATORYConsent for Treatment • September 17th, 2024
The acceptance of any services at or from the subsidiaries of Baptist Health System, Inc., which include our hospitals, outpatient services, and/or our physician practices (collectively, “Baptist Health”) constitutes an acknowledgment of, acceptance of, and agreement to, the following terms by you (the patient indicated below) or on your behalf (by the undersigned alternative decision-maker).
Consent for TreatmentConsent for Treatment • September 26th, 2022
Please read the following information carefully. After you have read this Consent and Agreement, please sign your name below to accept the terms of this agreement.
CONSENT FOR TREATMENTConsent for Treatment • June 15th, 2022
Treatment with Restylane, Juvederm, and other dermal fillers can smooth out folds and wrinkles, add volume to the lips, and contour facial features that have lost their fullness due to aging, sun exposure, illness, etc. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected into the skin with a very fine needle. The products produce a natural volume under the wrinkle, which is lifted up and smoothed out. The results can often be seen immediately. Treating wrinkles with these dermal fillers is fast and safe and leaves no scars or other traces on the face.
Consent for Treatment/Acknowledgment Agreement Signature Form Consent for TreatmentConsent for Treatment • December 31st, 2020
Patients must give voluntary consent for mental health treatment. Your signature (or that of your legal guardian) will demonstrate consent for receiving mental health treatment from the Psychiatric Wellness Center. I voluntarily consent to mental health treatment as performed by the Psychiatric Wellness Center and its employees. This treatment may include but not limited to: assessment, screening, consultation and recommendations, psychotherapy, holistic services and psychiatric medication management. I understand that mental health treatment may involve certain risks and benefits and I understand these risks and benefits. I also understand the risks and benefits of declining treatment. I am also aware that I have the right to request information about alternative treatment options, should they exist. I have read the above information and I authorize the Psychiatric Wellness Center to provide mental health services to myself or this patient (if guardian).
Acknowledgement of Agreement and Consent for ServicesConsent for Treatment • June 20th, 2019
By signing this document, I acknowledge that I have reviewed and fully understand the terms and conditions of this agreement. I have discussed such terms and conditions with staff at Glendale-Arcadia-Counseling (herein
Denton Psychological ServicesConsent for Treatment • November 14th, 2015
Welcome to Denton Psychological Services. This document/agreement contains important information about 1) our professional services, 2) summary information about the Health Insurance Portability and Accountability Act (HIPAA) and confidentiality, and 3) our business practices. Although a bit long and complex, it is important that you read it carefully and ask any questions you might have today or before our next session. We will give you a copy to take home. When you sign this document, it will represent an agreement between us.
