My name is Ashley Whitley.
As your mental health care provider, it is my obligation to provide you with the information you need in order to decide whether to consent to the treatment that I have recommended. The purpose of this form is to verify that you have received this information and give consent to treatment. I hold the following credentials: Licensed Clinical Marriage and Family Therapist (####, TX). Please read this form carefully
before signing.
Therapy is a process where mental health distresses and disorders are assessed, evaluated, and treated. There are a variety of techniques that can be used to provide relief and/or treat the mental health issues that have led you to seek therapy. These techniques and the therapy process have both benefits and risks. During our sessions, we will discuss the nature of your mental health concerns, the goals of treatment, and
any treatments I recommend. This discussion will also include the potential benefits, risks, or side effects of any recommended treatment. Possible risks include the experience of uncomfortable feelings (such as sadness, guilt, anxiety, anger, frustration, loneliness, or helplessness) or the recall of unpleasant events in your life. Potential benefits include significant reduction in feelings of distress, better relationships, better problem-solving and coping skills, and a resolution of specific problems. Given the nature of therapy, it is di cult to predict what exactly will happen,
but I will use my best efforts to address the risks and benefits. We will discuss the likelihood of achieving our treatment goals and reasonable alternatives, and you will be actively involved in your therapy journey. You fully acknowledge that any benefits from therapy is directly dependent upon your participation and my progression through therapy. However, no guarantees can be made regarding outcomes. At any time, you may refuse a recommended treatment, or revoke your consent to the treatment
altogether.