I hereby authorize the therapist named below to provide me with assessment and intervention / treatment as required. I further authorize them to communicate their findings to the referral source.
I have been told of the reasons for assessment and intervention / treatment.
I understand that the Therapist named below, and others under their supervision, as assigned, will be providing those services.
My therapist has explained any risks and the expected outcomes to me, and I understand the likely consequences of not receiving this assessment and treatment.