Consent for Services: Psychiatric Services Addendum
Name: Date of Birth:
Entry & Assessment
Participation in Therapy
Appointment Cancellation or Late Arrival
Potential Side Effects
My signature affirms that I have read and understand this form and have had the opportunity to ask questions.
This document is being signed by: ClientPersonal Representative, see below
If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.
Full legal name of Personal Representative:
Relationship to client:
Definition of Personal Representative:For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.
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Your legal name
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If you have questions about the contents of this document, you can email the document owner.
Document Name: Consent for Services: Psychiatric Services Addendum
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