Print and Sign
INFORMED CONSENT FOR TREATMENT
Patient Name ______________________________ SS# ___________________
I,
_______________________ (name of patient), agree and consent to
participate in mental health services offered and provided by
Roland Gabbert, LCSW, a mental health provider.
I
understand that I am consenting and agreeing only to those services
that the above named provider is qualified to provide within the scope
of the his license, certification and training.
If
the patient is under the age of eighteen (18), I attest that I have
legal custody of this child and am therefore allowed to initiate and
consent for treatment.
Signature_________________________________ Date ____________________
Relationship to Patient _______________________________________________
