Consent to Treat - Adult

Please read thoroughly answering all questions and sign to provide your consent for treatment.  Click 'submit' when done.

I provide my consent to participate in outpatient therapy services with therapist Lesa J. Fischer, LCSW at Madison Mental Health Services.
I understand that all services with therapist Lesa J. Fischer, LCSW and Madison Mental Health Services are voluntary. I understand that I have the right to refuse any aspect of treatment. I understand that I have the right to be informed by my therapist about a) the benefits, alternatives, side effects and aministration of treatment; and b) the consequences of not receiving the proposed treatment
I understand that all services with therapist Lesa J. Fischer, LCSW and Madison Mental Health Services are voluntary. I understand that I have the right to refuse any aspect of treatment. I understand that I have the right to be informed by my therapist about a) the benefits, alternatives, side effects and aministration of treatment; and b) the consequences of not receiving the proposed treatment
I understand that therapy is based on a trusting relationship between therapist and client, thus the therapist will keep information shared by the client confidential except in certain situations in which ethical responsibility limits this. These include: a) the client reveals information about hurting themself and/or another person; and b) the client or another person may be in physical danger.

© 2019 by Lesa J. Fischer, LCSW.