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Treatment Consent Acknowledgement


Your signature below indicates that you were offered, have read and agreed to the LHC office policies, HIPAA Notice of Privacy Policies, Crisis Information, and LHC treatment consent form.  These policies contain information on behavioral/mental health services, sessions, cancellation and no-show policies, billing and payments, insurance reimbursement, contacting us, professional records, confidentiality, and practice status; and you agree to abide by its terms during our professional relationship.


RELEASE FOR BILLING: By signing below you are giving consent to Life Healing Center, PC to release any medical psychiatric or psychological information deemed necessary to the appropriate insurance companies in order to bill for services rendered.  You are also agreeing to accept full responsibility of any balances, copays, and/or charges that are not covered by your insurance companies. 


CONSENT FOR TREATMENT: By signing below, you are giving consent to all treatment by Life Healing Center PC, its agents, employees and contractors as deemed necessary by your providers or his/her consultants, associates or designees.  You are giving informed consent to mental health treatment based on full, fair and truthful disclosure of known and reasonably foreseeable benefits, risks and hazards of the proposed treatment and of alternative treatments.  Please note; for continuity of care, your treatment plan, progress and case notes may be discussed with any member of the treatment team to provide an integrative approach to your care.


Patient or Parent/Guardian Signature


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