Consent to Treat - Minor

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

I provide my permission for my minor child 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 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. You will be notified if: a) child reveals information about hurting themself or another person; b) child or another person may be in physical danger.

© 2019 by Lesa J. Fischer, LCSW.