Informed Consent for Treatment Sample Clauses

Informed Consent for Treatment. I have read the above information, have asked questions as needed, and understand the issues related to the risks and benefits of psychotherapy, confidentiality, fees, professional records, length of psychotherapy, emergencies, and the rights of the client. Based on my understanding of these issues, I agree to proceed with treatment.
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Informed Consent for Treatment. I have requested that Xxxx Xxxxx, Ph.D provide individual psychotherapy. I understand that while Xx. Xxxxx will use her best efforts to assist me, the nature of services of this kind is that there can be no assurances or guarantees of results. I also understand my collaboration and regular attendance are key to facilitating treatment progress, and I agree to participate to the best of my ability. I understand that I have a right to refuse treatment and discontinue at any time. To avoid premature termination, I will not discontinue treatment by letter, email, telephone, or non-attendance. I agree to inform Xx. Xxxxx prior to any session which I intend to be my last. Initially, the frequency of therapy will be one session per week, unless otherwise agreed. I agree to pay my provider at the current rate of $250 per 50-minute session. Initial 80-minute intake sessions are $300. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. Patient’s Printed Name: (If under 18) Legal Guardian’s Printed Name: Patient or Legal Guardian’s Signature: Date:
Informed Consent for Treatment. Informed Consent involves a process of reaching an agreement to work collaboratively on behalf of the Client(s). This process begins with the Client reading and understanding the therapist’s disclosure (Psychotherapy Agreement) and signing the Informed Consent for Treatment. Do not sign this form until you:
Informed Consent for Treatment. I hereby agree and consent to participate in treatment/testing services provided by my provider. If the patient is under the age of 18 or unable to consent to treatment, I attest that I have legal custody of this individual and am authorized to initiate and consent for treatment and or legally authorized to initiate and consent to treatment on behalf of this individual. Signature: ............................................................................................. Date: ..................................... Relationship to Client (if applicable): .....................................................................................................

Related to Informed Consent for Treatment

  • Informed Consent Both of us have reviewed this Agreement with independent legal counsel. We understand the content, legal effect, and consequences of this Agreement, and we are entering into this Agreement voluntarily, free from duress, fraud, undue influence, or coercion of any kind.

  • Billing for Treatment and Payment Restrictions Grantees will;

  • Certification Regarding Debarment, Suspension, and Ineligibility (i) Paragraph 16.2, Governing Law;

  • Notification Regarding Letting/Transfer If the Allottee lets out or transfers the said Apartment, the Allottee shall immediately notify the Promoter/Association (upon formation) of the tenant’s/transferee's address and telephone number.

  • Consent to Medical Treatment 1. I authorize the School District and my child’s custodian to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment or hospital care which is deemed advisable by and is rendered under the general supervision of any licensed physician or surgeon, whether such treatment or diagnosis is rendered at the office of such physician or at a hospital.

  • Certification Regarding Debarment Party certifies under pains and penalties of perjury that, as of the date that this Agreement is signed, neither Party nor Party’s principals (officers, directors, owners, or partners) are presently debarred, suspended, proposed for debarment, declared ineligible or excluded from participation in Federal programs, or programs supported in whole or in part by Federal funds. Party further certifies under pains and penalties of perjury that, as of the date that this Agreement is signed, Party is not presently debarred, suspended, nor named on the State’s debarment list at: xxxx://xxx.xxxxxxx.xxx/purchasing/debarment

  • Certification Regarding Prohibition of Boycotting Israel (Tex Gov. Code 2271) If (a) Vendor is not a sole proprietorship; (b) Vendor has ten (10) or more full-time employees; and (c) this Agreement or any agreement with a TIPS Member under this procurement has value of $100,000 or more, the following certification shall apply; otherwise, this certification is not required. Vendor certifies, where applicable, that neither the Vendor, nor any affiliate, subsidiary, or parent company of Vendor, if any, boycotts Israel, and Vendor agrees that Vendor and Vendor Companies will not boycott Israel during the term of this Agreement. For purposes of this Agreement, the term “boycott” shall mean and include refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations with Israel, or with a person or entity doing business in Israel or in an Israeli-controlled territory but does not include an action made for ordinary business purposes. When applicable, does Vendor certify? Yes

  • Reporting Unauthorized Transactions You should notify us immediately if you believe your Access Codes or any Access Devices have been lost or stolen, that someone has gained access to the Security Procedure, or that someone has transferred or may transfer money from your Account without your permission or if you suspect any fraudulent activity on your Account. To notify us, call us at the number provided in Section 9.6 between 8:00 a.m. to 4:30 p.m. Central Time during a Business Day.

  • No Conflict; Required Filings and Consents (a) The execution and delivery of this Agreement by the Company do not, and the performance of this Agreement by the Company and the consummation of the Mergers (subject to the approval of this Agreement, the Mergers and the other transactions contemplated hereby by the Company Required Vote) and the other transactions contemplated by this Agreement will not, (i) conflict with or violate any provision of the Company Memorandum, or the equivalent organizational documents of any Subsidiary of the Company, (ii) assuming that all consents, approvals, authorizations and waivers contemplated by Section 4.05(b) have been obtained, and all filings described therein have been made, and assuming the accuracy and completeness of the representations and warranties contained in Section 5.05(b), conflict with or violate any Law applicable to the Company or its Subsidiaries or by which any property or asset of the Company or any of its Subsidiaries is bound or affected, (iii) require any consent or other action by any Person under, result in a breach of or constitute a default (or an event that with notice or lapse of time or both would become a default) under, give to others (immediately or with notice or lapse of time or both) any right of termination, amendment, acceleration or cancellation of, result (immediately or with notice or lapse of time or both) in triggering any payment or other obligations under, or result in the loss of any right or benefit to which the Company or any of its Subsidiaries is entitled under, any note, bond, mortgage, indenture, contract, agreement, lease, license, permit, franchise or other instrument or obligation or authorization (each, a “Contract”) to which the Company or any of its Subsidiaries is a party or by which the Company or any of its Subsidiaries, or any property or asset of the Company or any of its Subsidiaries, is bound or affected or (iv) result (immediately or with notice or lapse of time or both) in the creation of a Lien on any property or asset of the Company or its Subsidiaries, except in the case of clauses (ii), (iii) and (iv) for any such conflicts, violations, breaches, defaults or other occurrences that would not, individually or in the aggregate, reasonably be likely to have a Company Material Adverse Effect.

  • CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS The undersigned (authorized official signing for the contracting organization) certifies that the contractor will, or will continue to, provide a drug-free workplace in accordance with 45 CFR Part 76 by:

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