Psychotherapy and Psychological Assessment
Phone: 973.734.0780

Adult Treatment Consent

    Psychotherapy can have benefits and challenges. You and your therapist will work together to identify your goals and the means to create solutions for the issues you wish to address. This process of building a rapport and discussing important aspects of one’s life often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.

    I, give consent and authorization to receive clinical services from
    (name of therapist) at The Institute For Change, including diagnostic and psychotherapeutic procedures.

    I understand that I am responsible for the time set aside for service for me and that a charge will be made for such scheduled appointments if I do not keep them, unless 24-hours notice is provided. Insurance companies cannot be billed in such circumstances.

    I have read this form and any questions I had have been fully addressed. I understand its contents and agree to its terms.

    Signature
    Date

    The Institute for Change