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Consent for Therapy

 Karen Osborne-Rowland, MAEd., LCMHC

 

Osborne-Rowland Counseling, PLLC

2 South Main Street  Weaverville, NC  28787

828-768-5440    [email protected]

 

Informed Consent to Psychotherapy

Client Name:  ________________________________________

Insurance #:  ________________________________________

Date of Birth: ________________________________________

 

I consent to the use of a diagnosis in billing, and to release of that information and other information necessary to complete the billing process. Unless otherwise covered by my insurance, I agree to pay the fee of $___________________per session. I understand my rights and responsibilities as a client, and my therapist's responsibilities to me.

 

I understand that I have the right to contact the Governor’s Advocacy Council for Person’s with Disabilities at any time regarding any concerns about my care.

 

I agree to undertake therapy with Karen Osborne-Rowland, LCMHC . I know I can end therapy at any time I wish and that I can refuse any requests or suggestions made by Ms. Osborne-Rowland.

 

I have read this statement, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to ask, and understand it.

Signature:  _________________________________

Date:________________

 

Witness: ____________________________________

 

 

 

February 2020

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