Consent To Treatment

I do hereby seek and consent to take part in therapy with SpringSource Psychological Center, PLLC.

I acknowledge that I have received and understand the information about the therapy I am considering. I have had all my questions answered fully.

I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist.

I have discussed the fee and billing process with SpringSource Psychological Center, PLLC and understand my responsibility to ensure that sessions are paid in full. I understand that SpringSource Psychological Center, PLLC uses a billing service (Claims Recovery Service) and that I may be contacted by the service if information about benefits or eligibility is required to process claims.

I am aware that I may stop treatment with my therapist at any time. The only thing I will still be responsible for is paying for the services I have already received.

I know that I must call to cancel an appointment at least 24 hours before the time of the appointment. If I do not cancel and do not show up, I will be charged $100 out-of-pocket for that appointment.

I am aware that an agent of my insurance company may be given information about the treatments I receive. I understand that if payment for the services I receive here is not made, the therapist may stop my treatment.

I acknowledge that I have received the following documents: Consent to Treatment, Consent to Treatment for Teletherapy, Notice of Privacy Practices, and Consent to Use and Disclose Your Health Information

My signature below shows that I understand and agree with all of these statements.

    This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. This form has been modified from The Paper Office. Copyright 2008 by Edward L. Zuckerman.