Informed Consent & Service Agreement

NOTE: * indicates a required response.

I have read, understand, and agree to this Informed Consent and Service Agreement. I acknowledge that I am more than 17 years old and have the legal authority to bind myself, or others—such as a minor child—listed below, to this Agreement.* Yes No I give permission to have my sessions tape recorded. These recordings will be in lieu of physical note taking during the sessions.* Yes No I give permission for each of the following to be a means of communicating with me:* Telephone Email Text Message Name* Name(s) of Additional Client(s) Email* Verify Email Date

Thanks for completing and submitting the Informed Consent and Service Agreement. You will soon receive an email confirming I have received it.

By the way, be sure to complete and submit the Counseling Client Intake Form if you haven't already done so.

I look forward to meeting you at our first appointment,
Worth