Treatment in Therapy Consent Agreement

Treatment in Therapy Consent Agreement(Required)
You are required to read through the following terms and conditions. When you have reach the end, checking the box will satisfy the agreement to be submitted.


I hereby consent to treatment by the therapist / coach listed below.

I understand there is no insurance covering the costs of my treatment. I am responsible to pay for services at the cost of $150 per hour for individuals, and $180 per hour for couples / groups / families. Any appointments not cancelled with 24 hours notice may be subject to a $50 fee.

I understand there are no guaranteed outcomes for my treatment. My therapist / coach and I will work together to determine my treatment goals and the steps to reach the goals.

Anything I say in the sessions is confidential UNLESS: written permission has been given for release of information, a court order requires disclosure of some information or if I report or threaten harm to myself or others. My therapist / coach and I will work together as much as possible regarding any disclosure of information.

I will disclose to the best of my ability information asked of me related to my medical history, my family history, my experiences, and my expectations for our sessions. I will do my best to work with my therapist / coach to create and implement my goals.

I may stop our sessions at any time. I may ask my therapist / coach any questions regarding our work together and stop the treatment / coaching process until my questions are answered satisfactorily.

Any complaints or concerns regarding my therapist / coach or treatment will be brought directly to the attention of the therapist / coach.

If I am a child under the age of 18 my parent(s) will co-sign this form authorizing our working relationship.

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951 High Street Suite B Worthington, Ohio 43085