I have read and discussed the above information with my therapist.

I understand the qualification,

therapeutic approach and limits of the counselor, qualification, therapeutic approach and limits of the
counselor risks and benefits of the therapy, the nature and exceptions of confidentiality, and lastly, my
responsibilities as a client of the Counseling Services. I am fully aware that I can continue or end the
therapy at any time I desire and that I can refuse any requests or suggestions made by the therapist.

_________________________________ ______________________________

Name of Client Name of Therapist

_________________________________ ______________________________

Signature of Client Signature of Therapist

_________________________________ ______________________________

Date signed Signature of Witness (if any)