Supervision Disclosure Consent

Supervision Disclosure Consent Form

Creative Touch Counseling Center
Supervision Disclosure Statement

I understand that the person who provides my counseling and is responsible for my case management may be enrolled in a graduate level program or is a graduate level clinician in training or an associate level professional.

I understand this professional is practicing under the supervision of a qualified licensed professional and that my case may be recorded, discussed and reviewed for the purpose of professional development for the clinician. If this professional is a clinician in training, an LAPC, an LMSW, or an LAMFT who are unable to practice independently and require ongoing supervision in order to practice, I am giving my consent to be treated by this person.

The following out of pocket fees apply:

Minors (age 17 or younger)- $35 per 50 minute session

Adults (age 18 or older)- $50 per 50 minute session

Couples/Families- $60 per 50 minute session
CONSENT

I understand that this consent is purely voluntary. I have had the opportunity to discuss any concerns with regard to the services and treatment and by which all questions were answered accordingly and to my satisfaction.

I understand that I can withdraw anytime from the therapy by informing my therapist. By signing below, I expressly give my consent to the treatment and therapy sessions with the therapist.
Age of Consent*

I hereby declare that I am of legal age and I freely give my consent to this foregoing treatment.I hereby declare that I am below legal age and I am accompanied by my parent/guardian who gives his/her consent on my behalf for the foregoing treatment.
Name*

First NameMiddle NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Parent/Guardian

First NameMiddle NameLast Name
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
Should be Empty:

Supervision Disclosure Consent Form