Permission for Treatment and Cell Phone Consent

Permission for Treatment

I consent to receiving mental health treatment/psychotherapy (for myself or my child) from Tracy Riley Counseling.  These services may include diagnostic evaluations, individual therapy, family therapy, couples therapy, group therapy, or other standard therapeutic interventions.

I am aware that I may receive a mental health diagnosis, in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.  

I am aware that any therapeutic notes taken regarding my situation will be held in strictest of confidences.  I understand that even if I waive confidentiality, therapy notes will not be provided to anyone, for any reason, unless there is a court order issued by a Judge. 

I am aware that animals may be used for therapeutic purposes at this office and I give my consent for an animal to be near me.  If this does not apply to me, I will discuss it with office staff.

I understand that there are cameras monitoring the office lobby and hallway, both audio and video.  This is the safety and well-being of all who enter the office. 

I also give my permission to have my insurance or EAP billed directly.  

Cell Phone Consent

I acknowledge and agree that Tracy Riley Counseling and any affiliates or vendor thereof, including collection or billing companies, may contact me by telephone or text message to any telephonic number I have provided to you, and any other telephone number associated with my account, including wireless or mobile telephone numbers.  I further agree that you may use any method of contact to these numbers, such as an Automated Telephone Dialing System (ATDS) or prerecorded message.  I also agree that I will notify Tracy Riley Counseling if I have given up ownership or control of any such telephone number.