Consent for Assessment and Treatment Authorization Form

CONSENT FOR MENTAL HEALTH ASSESSMENT AND TREATMENT SERVICES

I (full name) * do hereby give my consent and authorize The American Board of Mental Health Diagnostics, aka: ABMHD, through any and all of its representatives, to commence with the provision of mental health services, inclusive of assessments, diagnostics, treatment, and collateral contacts as I have personally and specifically requested.

Revocation and Validity

I understand that I have the right to revoke this authorization, in writing, at any time.

Please Note that children over the age of 14 MUST also sign this Authorization

I do hereby give my consent for diagnostic, psychotherapeutic assessments, and treatment processes.

By checking the "Agree" box, and/or through signing, I ackowledge that I have read and understood all of the above.

By checking the "Agree" box, and/or through entering a full name, I ackowledge that I have read and understood all of the above.