Simon R. Downes, Ph.D., Psychologist email@example.com
Informed consent for psychological servicesUpdated: July 24, 2015
Please sign your name below, and initial where indicated to show that you have read the information in this document and agree to follow the terms during our professional relationship.
I have read and agree to the privacy and financial policies of Simon R. Downes, Ph.D., Psychologist. My written consent below indicates my acceptance of confidentiality policies and financial terms (fees and late-cancellation/no-show policies) of practice with Simon R. Downes, Ph.D., as well as my understanding of how to contact Simon R. Downes, Ph.D., in the event of a clinical emergency.
I, the client, understand I have the right not to sign this form. My signature below indicates that I have read and discussed this agreement only; it does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the therapist, before I start formal therapy. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in this information packet, I can talk with you about them, and you will do your best
to answer them.
I understand that after therapy begins I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with Simon R. Downes, Ph.D. before ending therapy. I understand that no specific promises have been made to me by this therapist about the results of treatment, the effectiveness of the procedures used by this therapist, or the number of sessions necessary for therapy to be effective.
I have read and understand the policies of Simon R. Downes, Ph.D., Psychologist. I agree to act according to the policies of his services. I hereby agree to enter into therapy with this therapist, as shown by my initials next to each of the following policies, and my signature below:
I, the therapist, Simon R. Downes, Ph.D., have met with this client (and/or his or her parent or guardian) for a suitable period of time, and have informed him or her of the issues and
I believe this person is fully aware and understands the issues, and I find no reason to believe this person is not fully competent to give informed consent to treatment. I agree to enter into therapy with the client, as shown by my signature here.
Signature of therapist
Simon R. Downes, Ph.D., Psychologist