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Relationship of signator to client
Client
Guardian
Legal Representative
Other
Parent
Physician
Plan executor
Witness
Name of signator(required)
Name of client associated with(required if relationship is not Client)
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By signing this document, you agree that: I have discussed with my therapist the assessment of my problems, the treatment plan / problems / goals / methods, treatment alternatives, and possible outcomes/side effects of treatment, my rights and responsibilities, as well as my therapist's rights and responsibilities in working on these treatment plans. I have received the hourly rates and the possible length and cost of services. I have received and understand the information given to me in the welcome letter, my confidentiality and data privacy rights and grievance procedures.
I agree
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