I acknowledge that I will be receiving services from a Doctoral level therapist who is not a licensed psychologist but rather who is working under supervision toward licensure. The therapist has completed all relevant coursework, supervised training practice, and has obtained a Doctorate degree in Psychology, and is now in supervision towards licensure.
By signing this form, I acknowledge that I am in agreement to receiving services from a Doctoral level therapist and that my personal health information will be reviewed by a separate BHC clinician.