Informed Consent Log KEEP Add Informed Consent Client's Rights The client may ask questions on what to expect during and end result of the therapy. The client may decline to proceed the therapy as to the techniques which may be conducted by the therapist. The client may cease to continue therapy anytime, without any impediment and may return to therapy anytime. The therapist has the right to dismiss the client from the course of therapy. The client has the right to review his or her records from the therapist. Right to confidentiality: Within limits provided for by law, all records and information acquired by the therapist shall be kept strictly confidential in accordance to the principles of a doctor-patient relationship. All information will not be shared or revealed to any person, agency, or organization without the prior written consent of the client. The client can raise any concerns and to speak with the therapist immediately of any concerns provided that the therapist is likewise available to discuss matters with the client. Additional Notes For Practitioner & Attendee Please check the items that you believe are affecting you Alcohol or drug problems Anxiety, nervousness, fears Eating or appetite problems Procrastination Relationship/marital concerns Shyness Social conflicts Stress Self-control Work or career concerns Anger or hostile feelings Sadness or Depression Family issues Physical distress Sexual concerns Traumatic experiences Suicidal feelings or behaviors Sleep disorder Self-esteem or confidence OtherOther Acknowledgement * I have reviewed this Professional Counseling Informed Consent Agreement. I likewise understand my Client's Rights set in this form. I accept this agreement and consent to counseling Client name * First Surname name * Last Email Confirm Email Additional notes Date * Signature * Clear If you are human, leave this field blank. Submit ADD NEW CLIENT No Entries Found!