I have discussed with the psychotherapist the purpose, risks, benefits and alternatives to the service, and that the psychotherapist believes that the service will be beneficial. I am seeking this service voluntarily because I too believe the service will be helpful even if not deemed medically necessary. Because my mental health managed care pan (has not) (will not, in the opinion of the psychotherapist) authorize payment, I understand and agree that the psychotherapist will not submit claims for this service on my behalf.