Willow Ann Rose LPC CHT ~ SpiritWell
PO Box 42114
Eugene, OR 97404
Phone: 541 461-5424
willowrose@spirit-well.com

CONSENT TO TREATMENT

I consent to and authorize Willow Ann Rose LPC CHT to provide Transpersonal Psychotherapeutic services to me. Services may include any of the modalities we have discussed, I have requested and have agreed to as part of our therapeutic work together.

I attest that I have read through Professional Disclosures (available on website) and if desired, discussed with my therapist, the contents of that document.

I have also reviewed and signed the Financial Agreement and agree and affirm I am responsible for payment of services rendered to me by

Willow Ann Rose LPC CHT~SpiritWell. I affirm that my request for services is voluntary and that I may discontinue at any time. I also understand that as set forth in her Professional Disclosure Documents, Willow Ann Rose LPC, CHT, may choose to discontinue our work together should I not abide by certain guidelines (as outlined in the Professional Disclosure Statements or Financial Agreement), or Ms. Rose determines that my needs and care would be better served by another practitioner. Should this occur, termination will always be discussed in advance.

I willingly agree to abide by all guidelines as set forth in this document.

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Form Revised July 2020