Informed Consent for Treatment
I give consent for evaluation and treatment to be provided for myself/my child
by	_	       .
I am aware that the practice of psychotherapy is not an exact science and that results cannot be guaranteed. No promises have been made to me about the results of treatment.
The risks, benefits, side effects, and alternatives of treatment as well as the consequences of non-compliance with treatment have been discussed with me and I have had the opportunity to ask questions.
I understand that I need to provide accurate information about myself to my clinician so that I will receive effective treatment. I also agree to play an active role in my treatment process.
I understand that I may terminate treatment at any time.
My signature below shows that I understand and agree with all of the above statements. I have had the opportunity to ask questions about the treatment process. If the client is a minor or has a legal guardian appointed by the court, the client's parent or legal guardian must sign this consent.
Signature of Patient or Parent/Guardian	Date
Printed Name
Relationship to Patient (if applicable)
Witness Signature	Date