1258 High Street, Eugene, OR 97401

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

Intern Therapist 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: 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.