BetterNOW Mental Health, LLC

    betternowmentalhealth.com
    Marian Aguwa, LCSW-S, BCD
    (248) 914-2675 – marianaguwa@gmail.com
    P.O. Box 131073 , Houston, TX 77219-1073

    Consent to Treat

    Client Name:

    Date of Birth:

    Today’s Date:

    I voluntarily consent to Tele-Mental Health services with Marian Aguwa, LCSW. I understand that I may terminate these services at any time, unless my participation has been mandated by a court of law.

    I understand BetterNOW Mental Health uses an integrative and comprehensive approach to counseling, and mental health.

    I agree to participate in the development and execution of an individualized treatment plan. I understand that consistent attendance and playing an active role is essential to my treatment’s success. Frequent cancellations, “no shows” or arriving late to treatment may be grounds for termination of services and also a failure to follow the agreed upon treatment plan.

    I understand that during the course of this treatment that I may need to discuss material of any upsetting nature in order to resolve my issues. I also understand it cannot be guaranteed that I will feel better after completion of treatment

    I have read and understand the foregoing and understand it is my responsibility to discuss any concerns I have about any and all parts of my treatment plan. I understand the nature of these health care methods and consent to counseling and treatment.

    Client’s Rights

    The client may ask questions on what to expect during and end result of therapy.

    The client may cease to continue therapy anytime, without any impediment and may return to therapy anytime.

    The therapist has the right to review his or her records from the therapist.

    Right to confidentiality: Within limits provided for by law, all records and information acquired by the therapist
    shall be kept strictly confidential in accordance to the principles of a doctor-patient relationship. All information will not be shared or revealed to any person, agency, or organization without the prior written consent of the client.

    The client can raise any concerns and to speak with the therapist immediately.

    The client has the right to be treated with dignity and respect by all staff.

    The client has the right to know about my treatment progress or lack thereof.

    The client has the right to reject the use of therapeutic technique, and to ask questions at any time about the methods used.

    The client has the right to be spoken to in a language that is fully understood.

    The client has the right to refuse to be videotaped, audio recorded, or photographed

    Signature of Client

    (Enter Your Full Name Here)

    Electronically Signed No Signature Needed

    Date

    Signature of Guardian

    (Enter Your Full Name Here)

    Electronically Signed No Signature Needed

    Date