Consent to Treat

Consent To Treat

The type and extent of services that I / my child will receive will be determined following an initial assessment and thorough discussion with me. The goal of the assessment process is to determine the best course of treatment for me/ my child. Typically, treatment is provided over the course of several weeks.
I understand that all information shared with the clinicians at Resto Family Services is confidential and no information will be released without my consent. Consent to release information is given through written authorization. Verbal consent for limited release of information may be necessary in special circumstances. I further understand that there are specific and limited exceptions to this confidentiality which include the following:
    A. When there is a risk of imminent danger to myself or to another person, the clinician is ethically bound to take    necessary steps to prevent such danger.
    B. When there is suspicion that a child or elder or dependent adult is being sexually or physically abused or is at risk of such abuse, the clinician is legally required to take steps to protect the individual, and to inform the proper authorities.
    C. When a valid court order is issued for medical records, the clinician and the agency are bound by law to comply with such requests.

I understand that while counseling may provide significant benefits, it may also pose risks. Counseling may elicit uncomfortable thoughts and feelings for me/my child, or may lead to the recall of troubling memories.

Name *

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Last

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Email *

Date of Birth *

Guardian Name and Email (if client under 18) *

Consent Agreement *

By checking and submitting form, I affirm that I have read the consent form and I consent to myself/my child participating in the evaluation and treatment offered to him/her by Resto Family Services. I agree to the terms of this consent. I understand that I may stop at any time.

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