Client consent form

Client Consent to Psychotherapy

I agree to undertake therapy with Trinity Treat, LPC.  I have received a copy of the Professional Disclosure Statement; had sufficient time to consider it carefully; and asked any necessary questions. I understand the limits to confidentiality, as required by law. I agree to pay the fee of $80.00 per fifty minute session. I understand my rights and responsibilities as a client, and my therapist's responsibilities to me. I may end therapy at any time I wish and I can refuse any requests or suggestions made by my therapist. I am over the age of thirteen.  


Signed: ________________________________________________________________