Atlanta

Child Therapy, Inc.

INFORMED CONSENT FOR TREATMENT

Childs Name: ___________________________________________________ DOB: ________________________

Parent or Guardians Name: ________________________________________________
Address: ________________________________________________________________________________________

I hereby give my authorization and consent for my child to receive outpatient diagnostic and
treatment services at Atlanta Child Therapy, Inc.

PLEASE READ THOROUGHLY AND INTITAL NEXT TO EACH STATEMENT

1. ______

I release pertinent information to the office staff at Atlanta Child Therapy, Inc. (to
include, but not limited to, Dr. Patricia Crawford) and my insurance company to
complete any needed paperwork and billing.

2. ______

I have been giving information regarding my rights and responsibilities as a

participant.

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 from Atlanta Child
Therapy, Inc. I understand that I am responsible for all costs of these services and that
payments for all costs due are expected at the time of treatment.

5. ______

I have been informed of my clinicians level of licensure and training and of how
clinical information may be used within a supervisory relationship.

6. ______

I understand that I am encouraged to address any concerns or grievances with my

therapist, and/or the supervisor at any time.

7. ______

I am freely choosing to enter into treatment, and I understand that I may discontinue
treatment at any time.

8. ______

I understand that the full cost of sessions will be charged if cancelation is not given at
least 24 hrs. prior to my scheduled appointment. I understand that it is my
responsibility to cancel and/or reschedule my appointment with my therapist.
Atlanta Child Therapy - a Georgia-based 501c3 non-profit educational therapy corporation
2950 Cherokee Street, NW, Building 500, Kennesaw, Georgia 30144
Atlantachildtherapy.org 678.903.5506

9. ______

I understand that I am responsible for any balances due for treatment, and it is my
responsibility to pay all costs in a timely manner.

10. ______ Time spent in support services such as reviewing documentation, writing requested
reports/letters, attending and/or preparing documentation for court, or email or
phone contact between sessions, will be charged at a prorated rate per hour. These
services are not covered by insurance and will be billed directly to the client.
11. ______ I have been given information about my right to confidentiality under HIPPA
regulations and I understand that I have to right to file a complaint with HIPPA at any
time by visiting the US Department of Health and Human Services.
12. ______ I have been informed that HIPPA rules are posted in the waiting room of Atlanta Child
Therapy, Inc. and that I have the right to read them at any time.


PRINTED NAME OF PERSON COMPLETING THIS FORM

__________________________________________________________________

SIGNATURE OF PERSON COMPLETING THIS FORM

DATE

________________________

__________________________________________________________________

Atlanta Child Therapy - a Georgia-based 501c3 non-profit educational therapy corporation

2950 Cherokee Street, NW, Building 500, Kennesaw, Georgia 30144
Atlantachildtherapy.org 678.903.5506