Introduction

This form documents informed consent before receiving any psychological or psychiatric service at the center. The patient has the right to ask questions, receive information in a clear manner, and make a voluntary decision to proceed.  

Clinical capacity to consent is evaluated as part of the medical record.

Description of Services

The center provides psychotherapy, group therapy, psychiatric assessments, and medication management. Therapy may improve psychological health but may also involve temporary discomfort. All services are conducted by qualified professionals and evaluated regularly.

Consent to Treatment

☐ I confirm that I received clear information about the therapy/service.

☐ I understand the risks and benefits involved.

☐ I voluntarily consent to receive the proposed service.

Confidentiality

Sessions are confidential unless disclosure is required by law, or there is risk of harm to self or others.

Cancellations and Unattendance

I acknowledge that late cancellations (less than 24 hours notice) or no-shows may result in a compensatory service fee, due to the operational and scheduling impact on the center and provider.

Damage to Property

I agree to be held financially responsible for any intentional or negligent damage I cause to the center’s property or equipment.

Emergencies

I understand that the center does not provide emergency psychiatric care outside working hours, and I am advised to contact 911 or the nearest hospital in such cases.