Treatment Contract

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8336 Monroe Rd. Suite 120 Lambertville, MI 48144 Phone: (734) 807-0162 Fax: (888) 700-7159

Treatment Contract

By signing below, I acknowledge I have been given an opportunity to read and understand the HIPPA privacy policy, the informed consent/office policies for services, and the disclosure statement. I understand that my counselor will discuss treatments goals as part of the therapy process. If needed, I agree to talk with my counselor to clarify the above.

I have been informed of the risks, approximate length of treatment, and the possible consequence of deciding on counseling which may include the following methods and interventions: stabilization; decrease and relieve, symptomatology; improve coping, problem solving; use of resources, skill development; grief resolution; stress management; behavior modification and cognitive restructuring.

While I expect benefits from counseling, I understand and accept that because of factors beyond the control of Bedford Behavioral Health and its clinicians, such benefits and desired outcomes cannot be guaranteed. I have been informed of whom/where to call in case of an emergency or during the evening or weekend hours. I understand that regular attendance will produce the maximum possible benefits but that I am free to discontinue counseling at any time.

I have had the opportunity to discuss aspects of counseling, have had my questions answered, and understand the counseling process to the best of my ability. I give permission to provide mental health and/or drug/alcohol treatment or me or my dependent.

Therefore, I agree to begin counseling services

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Signature of Client/Legal Guardian Date

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Signature of Witness Date