This is an agreement that is used between a counselor and a client to establish the
rules and guidelines of the treatment. This agreement provides that the client agrees
and consents to the treatment and understands that he or she is responsible for
services rendered by the counselor. Additionally, the client agrees to notify the
counselor at least 24 hours in advance for any canceled appointments. This agreement
should be used by counselors who provide treatment to clients in order to inform the
client of their duties and responsibilities regarding treatment.
Consent to Counseling
I acknowledge that I have received, have read (or have had read to me), and understand the information
about the counseling I am contracting. I have had all my questions answered fully.
I do hereby seek and consent to take part in the treatment by the counselor named below. I understand that
developing a treatment plan with this counselor and regularly meeting the treatment goals are in my best
interest. I agree to play an active role in this process.
I understand that no promises have been made to me as to the results of treatment or of any procedures
provided by this counseling, and in fact I may receive no benefit whatsoever, I have been informed as to the
meaning of caveat emptor.
I am aware that I may stop my treatment with this counselor at any time; however I will be responsible for
any services I have received. I understand that I may have to deal with other problems, if I stop treatment
especially, if my treatment has been court-ordered.
I know that I must call to cancel an appointment at least 24 hours before the time of the appointment. If I do
not cancel or do not show up, I will be charged for that appointment.
I am aware that an agent of my insurance company or other third-party payer may be given information
about the type(s), cost(s), date(s), and providers of any services or treatments I receive in order for
My signature below shows that I understand and agree with all of this consent to treatment.
I, the counselor, have discussed the issues above with the client. My observations of this person's behavior
and responses give me no reason to believe that this person is not fully competent to give informed and willing
Signature of counseling Date
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