Consent for Services

I authorize Branched Out Therapy, Inc. to render appropriate evaluation and/or therapy services to the client named below in accordance with state and federal laws. I understand that care will be provided by a qualified, licensed, and trained health professional. I recognize, agree and understand that I have the right to refuse treatment or terminate services at any time by Branched Out Therapy, Inc. in writing. In addition, Branched Out Therapy, Inc. may terminate services by notifying me in writing.
I do not give my consent or am withdrawing my consent regarding Branched Out Therapy, Inc. rendering evaluation and therapy services to the client named below.

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Name of Client *

Signature of Client or Legal Representative *

Client Date of Birth *

Relationship to Client *