I hereby authorize the SMart Center to conduct therapy for myself.
The clinician facilitating this treatment group is providing services as part of his/her advanced clinical training in the doctoral program in Psychology, and I agree with this arrangement. I understand that my case will be discussed and reviewed with a licensed psychologist who is providing supervision and oversight to care.
I understand that I will not receive a refund in the event I need to cancel my registration. If I give the SMart Center 24 hours' notice, I will be able to transfer my registration to a future date/time.
I understand that information disclosed during the course of therapy is confidential and may not be released without my consent, except in limited situations, including but not limited to the following: potential harm to self or others, a medical emergency, specific court orders, suspected or reported child abuse/neglect, abuse of an older adult, or when services are not paid for in a timely manner.
I, the client (or person acting for the client), agree to pay this office’s fee of $30/session.