Mary Slominski Counseling
Consent for Treatment
Authorization for Treatment: I hereby authorize Mary Slominski (service provider,)
and/or designees in charge of my care to administer any treatment as maybe
necessary or advisable in my diagnosis and treatment at Mary Slominski Counseling.
I am aware that the practice of behavioral healthcare is not an exact science and I
acknowledge that no guarantees have been made to me as results of treatment and
therapy receive at Mary Slominski Counseling. I acknowledge that my care is under
the direction of my service provider(s) and Mary Slominski Counseling will follow the
instructions of my service provider(s) in the provision of said care.
I have been informed about my service provider's credentials.
I understand that Mary Slominski Counseling will secure emergency medical services
for me or my family member in the case of an apparent medical emergency while in
the Mary Slominski Counseling office or during services provided to me outside of the
Authorized Representative: I hereby authorize Mary Slominski Mary Slominski
Counseling and representatives to act on my behalf to recover benefit claims, appeal
adverse benefit determinations, and to take any action deemed necessary to obtain
payment for services provided to me by Mary Slominski and/or Mary Slominski
The undersigned certifies that he or she has read the forgoing, is the client, client's
guardian, power of attorney or parent, or is duly authorized by or no behalf of the
parent to execute the above and accept its terms.
Signature of Client or Parent/Guardian Date
Signature of Witness Date