Consent to Services
I have read and understand the “Professional Disclosure Statement” form and have had all my questions answered fully.
I seek and consent to take part in services with Kathryn Blount, LPC. I understand that developing my goals with Kathryn and regularly reviewing my progress are in my best interest. I agree to play an active role in this process.
I understand that no promises have been made to me regarding the results of counseling and coaching. I am aware that I may stop sessions at any time. I will still be responsible for paying for services I have already received.
I am aware that an agent of my insurance company or other third-party payer may be given information about the type, cost, date and providers of any services I receive.
My signature below shows that I understand and agree to all these statements.
Client Signature Date
Parent/Guardian Signature (if client is a minor) Date