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INFORMED CONSENT FORM
Client Name
Date of Birth
I hereby voluntarily consent to receive consultative, diagnostic, and therapeutic services and/or procedures from HIGHTOWER BEHAVIORAL SERVICES as listed below: Psychosocial Assessment Family Therapy Individual Therapy Medication Management Group Therapy
I understand the benefits of each service as well as the alternative to recommended treatment. Unless specifically stated otherwise, this consent form expires upon completion of services from HIGHTOWER BEHAVIORAL HEALTH. I further understand that I am free to withdraw this consent for services at any time without prejudice to receiving alternative services from HIGHTOWER BEHAVIORAL HEALTH. I may also be discharged from HIGHTOWER BEHAVIORAL HEALTH if there is non-compliance with the agreed upon services.
Client/Parent/Guardian Signature
❌
Date
NEXT: LIMITS OF CONFIDENTIALITY
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