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, MA Ed., LCMHC #6934. 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.

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Client Signature                                                                                Date

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Parent/Guardian Signature (if client is a minor)                                                Date