Mental Health Intern Disclosure Statement


1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Mental Health Intern Disclosure Statement

Name:     Date of Birth:

I understand that my therapist is an intern who is enrolled in a graduate program working toward a master’s degree, which requires direct client contact hours. I understand that my therapy sessions will contribute to this requirement. I further understand that my therapist is supervised weekly by a qualified Clinical Supervisor.

I have read and understand this form.  I have had the opportunity to ask questions.

I agree to provide at least 24 hours’ notice of cancellation of an appointment.

This document is being signed by:

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.


Leave this empty:

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Document name: Mental Health Intern Disclosure Statement
lock iconUnique Document ID: dac2528af6d146e9f38b6d9f4297e9a6fbf9a2d6
Timestamp Audit
September 24, 2020 3:39 pm PDTMental Health Intern Disclosure Statement Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202
September 24, 2020 3:56 pm PDTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129
March 18, 2021 2:52 pm PDT Document owner jdooley@c-f-d.org has handed over this document to donotreply@c-f-d.org 2021-03-18 14:52:22 - 65.157.96.202
March 18, 2021 2:52 pm PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
May 3, 2021 9:26 am PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202