Couples Therapy Behavioral Health Consent Form

This consent form is intended to provide information regarding behavioral health services for couples therapy. Please read the following carefully and indicate your understanding and agreement.

Information about Couples Therapy

Confidentiality

Limits of Confidentiality

Risks and Benefits of Therapy

Voluntary Participation

Client Information

Client 1 Name

Client 2 Name

Client 1 Date of Birth

Client 2 Date of Birth

Consent

I have read and understand the information provided above. I consent to participate in couples therapy. My questions about this consent and therapy have been answered.

Signatures

Client 1 Signature Date

Client 2 Signature Date

Therapist Use Only

Therapist Name Therapist Signature Date