I understand that   therapist's name   is an   AMFT      Associate Marriage and Family Therapist orACSW/APCC   Associate Clinical Social Worker in the State of California or Associate Professional Clinical Counselor and supervised by ___Janet Bayramyan, LCSW (LCSW 88575). My signature below acknowledges the following:

1) I authorize and request that   therapist's name  and, Janet Bayramyan, LCSW (LCSW 88575), to carry out psychological evaluations, treatment procedures, which now or during the course of my care as a patient are advisable. I understand that I can ask questions regarding the purpose of these procedures and that I have the right to be aware of all aspects of the working relationship. I understand that I have the right to participate actively in all aspects of treatment planning and that I can discontinue treatment at any time. I also understand that while the course of therapy is designed to be helpful, it may at times be difficult and uncomfortable.

2) I acknowledge that I have reviewed IPG’s Contract for Professional Psychotherapy Services. I understand and agree to comply with these policies. I understand that the aforementioned contract is available on IPG’s website, but that I can always request a hard copy if I am unable to access it.

3) I acknowledge that I have reviewed the HIPAA Notice of Privacy Practices. I understand that the HIPAA notice form is available on IPG’s website but that I am always request a hard copy if I am unable to access it.

I hereby consent to treatment