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«BERKELEY • DAVIS • IRVINE • LOS ANGELES • MERCED • RIVERSIDE • SAN DIEGO • SAN FRANCISCO SANTA BARBARA • SANTA CRUZ HOSFORD ...»

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Benefits & Risks: Although there are many potential benefits to mental health treatment (e.g., better relationships, improved self-esteem, reduction of specific symptoms), it can also be difficult at times. Part of the work during treatment is to talk about things that are difficult to discuss and may bring up unpleasant feelings. It is important for your minor child or dependent adult to let his or her clinician know when he or she is experiencing these feelings so that the clinician can be helpful. Sometimes a client may stop coming to treatment when it gets hard because they don’t realize that discomfort is a natural part of the process. The more consistently the client comes to treatment, the more value he or she will get from it.

You have a right to receive a copy of any consent form that you sign and of any written consent documentation that is used in obtaining your consent.

CONSENT TO TREATMENT

I hereby authorize the UCSB Hosford Counseling and Psychological Services Clinic to provide

psychological assessment and treatment services to:

(Name of minor/dependent adult)

I HEREBY CONSENT TO ALL OF THE TERMS AND CONDITIONS STATED IN THIS

CONSENT FORM, INCLUDING TO THE DIGITAL RECORDING OF ANY OR ALL THERAPY

SESSIONS WITH A STUDENT CLINICIAN.

–  –  –

___________________________________________ ______________________________

Name of Minor/ Dependent Adult Client (please print) (Date of Birth) ___________________________________________

Signature of Parent/Legal Guardian/Conservator Date ____________________________________________

Name of Parent/Legal Guardian/Conservator (please print)

–  –  –

_____________________________________________

Name of Clinician (please print) (license # if applicable)



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