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.
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Your legal name
Your email address
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Document Name: Intern Therapist Disclosure Statement
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