Client Information

Full Name Date of Birth Address Phone Number Email

Consent

I hereby consent to participate in mental health services provided by the practitioner. I understand that these services may include assessment, counseling, therapy, and/or consultation.

I have read and understand the above information.

Confidentiality

I understand that all information shared with the practitioner is confidential except in situations where disclosure is required by law.

I understand the limits of confidentiality.

Risks and Benefits

Please indicate any questions or concerns regarding risks and benefits of mental health services.

Emergency Contact

Name Phone Number

Signature