As your treatment provider, I want you to have as much information as possible about the treatment process. This form is designed to allow you to give informed consent to treatment.
Please correct the errors described below.
Please read each of the statements below and type your initials next to each point to indicate your consent.
1. I agree to participate in psychotherapy and/or nutrition therapy with Carol Park, LPC-S, CEDRD, RD, LD, who is a licensed professional counselor and registered and licensed dietitian.
2. I have read and understand the limits of confidentiality page.
3. I have read and understand the financial responsibility and cancellation policy agreement.
4. I am aware that there are times when “things may get worse before they get better.” This is especially true when dealing with traumatic events or when confronting very unpleasant or painful issues.
5. I understand that no guarantee can be made regarding the outcome of therapy. Therapy outcome is influenced by a variety of factors including therapist factors, client factors, and circumstantial factors. Every effort will be made to reach the agreed-upon goals as efficiently as possible.
6. I understand that my therapist is not a medical doctor and can therefore not recognize or diagnose medical conditions. I agree to obtain a medical examination as deemed necessary in the course of my treatment.
7. I am aware that I may always say “no.” If there is any interaction with which I am uncomfortable, I have the right to ask for clarification or to simply refuse.
8. I understand that in an emergency situation I should call 911 or go to the nearest hospital emergency room.
9. I am aware that I may stop treatment at any time. It is generally in the best interest of all concerned if there is a termination session. A termination session allows one to experience a greater sense of closure to the therapy process. Moreover, graceful terminations can enhance our skills in managing relationships.
I provide full informed consent to treatment as reflected in the above statements.