Therapy Consent Form

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* 1. Name:

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* 2. Phone number:

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* 3. Email address:

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* 4. Acknowledgements:

INSERT YOUR CONSENT TERMS HERE

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* 5. I consent to participate in therapy given the acknowledgements above:

I consent

I do not consent

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* 6. Signature:

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* 7. I acknowledge that by entering my name above I am providing a digital signature.

Agree

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* 8. Date:

Date

Date