Informed Consent for Services

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By submitting this form, I hereby authorize In Touch Counseling Center, LLC to provide individual and family therapy services. I understand that consenting to treatment constitutes allowing my insurance to be billed for services rendered and that all HIPPA and Confidentiality practices will be followed when receiving services at In Touch Counseling Center, LLC. I understand this treatment is voluntary and these services can be terminated by myself or my therapist at any time.

Full name

Client Signature

Date

Guardian Signature (if 12 or older)

Date

Witness

Date