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 2021