Informed Consent for Treatment Informed Consent for Treatment Form Leave this field blank Informed Consent for Treatment I, do voluntarily consent to care and treatment by Michael Payne, MSW, LCSW, LICSW, who is licensed to practice Clinical Social Work in the District of Columbia, Florida, and Virginia. I understand that healing arts are not an exact science and that no guarantees are being made as to the result or evaluation of treatment. I am aware that I am an active participant in my therapy and that I share the responsibility for the treatment process. Through the process of treatment, I am working toward changes and recognize that I may experience many different and intense feelings as a part of this process, some of which may be painful. I also understand that when I make changes in myself, I may experience changes in other areas of my life (e.g., family, work, social life). Every change has the potential for both positive and negative outcomes. I understand that our work will be kept strictly confidential with the exceptions of legal limitations on confidentiality. I also understand that I can contact the nearest public emergency mental health service by calling 9-11 if I am unable to contact my therapist or their designee. This form has been fully explained to me and I certify that I understand its contents. Client Signature I agree that my name below will be as valid as a handwritten signature to the extent allowed by local law Start Drawing Clear Done Start Over Date Co-Signature I agree that my name below will be as valid as a handwritten signature to the extent allowed by local law Start Drawing Clear Done Start Over Date Send
