Therapy Contract

  • Family Revelations Inc. CONTRACT FOR TREATMENT

      By signing this form, I the client/parent/guardian acknowledge the following on behalf of myself or the client entering therapy:
    • I have read (or have been read to) and understand all sections of the following forms for Family Revelations Inc.:
      • Notice of Privacy Practices and Bill of Rights
      • Financial Agreement
      • Communication Agreement
      • Authorization to Process Insurance
      • Consent for Release of Information
    • I have read the Financial Agreement for Family Revelations Inc. and understand that it only applies to me IF I am the “Identified Patient” (the one who is the official patient and who will have the file). I understand that this will be established with my therapist at the beginning of treatment. If I am the “Identified Patient”, I understand that there will be late fees for missed appointments and cancellations. I also understand that it is ultimately my responsibility to verify any insurance benefits I may have, and that I will be responsible for all therapy costs if my insurance does not reimburse the therapist.
    • I have had a chance to ask questions regarding these forms and have discussed any portion that I did not fully understand. At this point, I have had all my questions answered.
    • I understand that I have a right not to sign this form
    • If at any point during therapy I have questions regarding information contained in the documents listed above, I can ask questions and my therapist will do his or her best to answer them.
    • I understand that no specific promises have been made to me by my therapist about the results of treatment, the effectiveness of the procedures used by therapists employed by or contracted with Family Revelations Inc., or the number of sessions necessary for therapy to be effective.
    • I understand that the process of therapy often involves facing difficult issues and emotions. As part of the healing process sometimes things may seem to get worse before they get better.
    • I understand that I have the right to withdraw my consent to therapy at any time for any reason. However, I also understand that it is best to discuss difficulties or concerns about treatment and work to resolve them before taking actions to terminate he therapeutic relationship.
    I AGREE to act in accordance with the sections described in this document, and therefore enter into therapy at Family Revelations Inc.. Furthermore, I AGREE to cooperate with my therapist to the best of my ability. These agreements are shown by my signature below.  
  • Date Format: MM slash DD slash YYYY
  • If the client is under 18 or has a legal guardian, a parent or guardian must also sign. The parent/guardian of a divorced child must bring a copy of the custody agreement indicating the right to enroll their child in therapy.

    I am the legal parent/guardian and legally consent for their treatment.

  • Date Format: MM slash DD slash YYYY