Unformatted text preview: [ FORM 13 —Use the top of this page for your letterhead.] Consent to Treatment I acknowledge that I have received, have read (or have had read to me), and understand the “Information for Clients” brochure and/or other information about the therapy I am considering. I have had all my questions answered fully. I do hereby seek and consent to take part in the treatment by the therapist named below. I understand that devel- oping a treatment plan with this 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 this therapist. I am aware that I may stop my treatment with this therapist 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 theother problems if I stop treatment....
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- Spring '10
- English-language films, therapist, The Red Chord