CONSENT FOR TREATMENT

I share an office with Charis Family Clinic and Greenlee Counseling.  I am an independently practicing professional.  I am completely independent in providing you with clinical services and I alone am fully responsible for those services.  My professional records are separately maintained and no one else can have access to them without your specific, written permission.

 The undersigned patient or responsible party (parent, legal guardian or conservator) consents to, and authorizes services, by Denise Ibrahim, MS, CRC, LMHC.  These services may include psychotherapy, biofeedback, and other appropriate alternative therapies.   This consent also maintains that you were given a notice of my privacy practices describing how health information about you may be used and disclosed and how you can get access to this information. 

 The undersigned understands that he/she has the right to:

 1.                 Be informed of and participate in the selection of treatment modalities.

 2.                 Receive a copy of this consent.

 3.                 Withdraw this consent at any time.

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Signature of Patient                                                                                                Date Signed

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Signature of Parent, Legal Guardian or Conservator                                                Date Signed

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Signature of Witness (if appropriate)                                                                                                      Date Signed