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Consent for Treatment
Date of Birth
Consent for Treatment
I hereby give my consent to my clinician, Rebecca K. Lowry, MA, LCMHC (N.C. license #4137) to provide evaluation, treatment and/or other services that we may mutually determine to be appropriate. I understand that services will be rendered in a professional manner, consistent with accepted ethical standards.
I understand that I will likely gain the most benefit from counseling if I am committed to the process and attend regularly. I also understand that it is not uncommon, over the course of therapy, to temporarily experience increased distress. This is an indicator that important work is underway and significant changes are beginning. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist.
I acknowledge that I have received, have read the professional disclosure sheet and the HIPAA information sheet. I understand that I may ask questions at any time about any of the information given to me, and about treatment options.
I understand that the fee for the initial assessment is $130, and the fee for subsequent sessions is $90 for a 45-minute session and $120 for a 55-60-minute session. Several insurance providers and other referral sources with funding are accepted for payment. I have read the office policies and fee schedule and understand that I must cancel an appointment at least 24 hours before the scheduled time. Otherwise, I will be financially responsible for the full fee for the session. Payment will be due and payable to the therapist at the beginning of each session unless other arrangements have been negotiated. Please come prepared to pay by cash, check, or credit/debit card.
I understand that if payment for services I receive here is not made, the therapist may stop my treatment.
I understand that I may discontinue my involvement in therapy at any time. If I choose to do so, I will inform my counselor of my decision.
Due to the typical work schedules of counselors, I understand that it may take my counselor up to 48 hours to return a phone call. If at any time during treatment I cannot wait for a return call from my counselor, I agree to contact my psychiatrist, family physician, or go to the nearest emergency room.
Signature of Responsible Party
Consent for Treatment of Children and Adolescents:
I/We consent that [minor child] may be treated as a client or clients by Rebecca Lowry, MA, LCMHC.
Please list child/adolescent's name below.
Signature of Parent or Guardian