Psychotherapy and Psychological Assessment
Phone: 973.734.0780

Child/Adolescent Treatment Consent

    I, give consent and authorization for
    to receive clinical services from the staff of The Institute For Change, including diagnostic and psychotherapeutic procedures.
    Name of IFC Therapist:

    I understand that I am responsible for the time set aside for service for me or my family members and that a charge will be made for such scheduled appointments if they or 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.

    Patient’s Signature if 14 years or older (optional)



    Signature of Parent or Legal Guardian (required)
    Date

    The Institute for Change