I hereby request that I, (Name)

born (Date of Birth), be accepted for mental health and/or alcohol and drug

abuse treatment by Impact Behavioral Health. By my signature below, I agree to the

following statements.

1. I give my authorization and consent to receive outpatient diagnostic and treatment services from Impact Behavioral Health.
2. I have been given information regarding my rights and responsibilities as a patient.
3. I have been given information regarding the limits of confidentiality of my records.
4. I have been given information regarding the cost of services. I understand that I may be responsible to pay a co pay and that it is payable each time I come for treatment.
5. I understand that I may address any concerns or grievances with my therapist at any time. I understand that I may also contact the licensing board, which regulates my therapist’s professional practice.
6. I am freely choosing to enter into treatment, and I understand that I may discontinue at any time.
7. I have been given information about the advantages and disadvantages of the treatment recommended as well as other alternatives.

Parent or Guardian:

I, , do hereby state that I am the natural

parent or legal guardian of the patient; therefore, I am authorized to make this request for and give my consent to the treatment and services mentioned in this form.