Dual Diagnosis Behavioral Health Consent Form

Client Name Date of Birth Date

Consent for Assessment and Treatment

I hereby consent to participate in behavioral health services, including assessment and treatment for dual diagnosis (co-occurring mental health and substance use conditions).

Purpose of Services Types of Services to be Provided

Potential Risks and Benefits

Confidentiality and Limitations

Client Questions/Concerns

Client Signature Date

Clinician Name Clinician Signature Date