Consent to Treatment 

I hereby authorize and give consent to Heidi Chinlund, LCSW, through Purple Cactus Counseling, LLC to provide Counseling Services deemed necessary in my best interest. I hereby indemnify and hold harmless Purple Cactus, LLC and Heidi Chinlund, LCSW, (the Service Provider) who acts in reliance upon this authorization.

I do hereby seek and consent to take part in the treatment through Purple Cactus Counseling, LLC. I understand that developing a treatment plan with my therapist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process.

I understand that no promises have been made to me as to the results of treatment or of any procedures provided by Purple Cactus Counseling, LLC. 

I am aware that I may stop my treatment with Heidi Chinlund, LCSW through Purple Cactus Counseling, LLC at any time. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.)

I know that I must call to cancel an appointment at least 24 hours (1 days) before the time of the appointment. I understand that by cancelling within 24 hours of appointment may result in me owing a $25 fee to Purple Cactus Counseling, LLC. I understand these services are Self-Pay, and payment is required prior to each session. No insurance or third party payer will be accepted. 

This authorization shall remain in effect until conclusion of treatment or if revoked in writing. 

My signature below shows that I understand and agree with all of these statements. 

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 Printed name                                                 Signature of client						                                Date  

I, the therapist, have discussed the issues above with the client. My observations of this person’s behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent. 

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Signature of therapist 											Date 

This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.