Consent to Treatment
I do hereby seek and consent to take part in treatments at the Feeling Good Therapy and Training Center (FGTTC). I understand that developing a treatment plan with my treating psychologist or therapist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process.
I understand that no promises have been made to me as to the results of treatment or of any procedures provided by my provider at Feeling Good Therapy and Training Center.
I am aware that I may stop my treatment at FGTTC at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.)
I know that I must call to cancel an appointment at least 48 hours (2 business days) before the time of the appointment. If I do not cancel and do not show up, I will be charged for that appointment.
I am aware that an agent of my insurance company or other third-party payers may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive. I understand that if payment for the services I receive here is not made, the psychologist/therapist may stop my treatment.
I am aware that as part of quality assurance, my psychologist or therapist may share some aspects of my case and/or my treatment with her/his colleagues at FGTTC or within the community of psychologists/therapists she/he works with. I understand that the sole purpose of such case consultation is to improve the care that I receive and my treating psychologist/therapist will disclose no personal or identifying information to her/his colleagues within FGTTC or those outside of the center.
I understand that my services at FGTTC do not extend to child custody cases. We do not and will not make any child custody recommendations when treating a minor who is involved in a custody conflict. Parents and guardians who agree to engage our services for their minor contract that as the treating psychologist/therapist, we will not be called to testify or have records subpoenaed for any and all matters relating to custody conflicts. If there is any initial report made to Child Protective Services, parents and guardians agree to contract for release for the psychologist/therapist to have follow-up contact with Child Protective Services. Likewise, we do not and will not agree to make any psychological evaluations, provide clinical services, or serve in any other ways for the purposes of fulfilling a court-ordered, mandated, or otherwise legally required clinical task.
My signature below shows that I understand and agree with all of these statements.