Consent Form

Patient Information:

Name:
Date of Birth:
Address:
Phone Number:
Email:
Emergency Contact:
Purpose of Services:

I hereby consent to receiving psychological services from the Psychology Department at

encompassing assessments, counselling, and interventions tailored to my needs.

Confidentiality:

I acknowledge the psychologist's commitment to maintaining confidentiality, except in

circumstances involving abuse, imminent harm, or legal mandates.

Consent:

I offer my voluntary consent for treatment and confirm that my queries have been addressed.

Patient Signature: ___________________ Date: ___________

Parent/Guardian Signature (if patient is a minor): _________ Date: _______

[Date of Revision:] _________ [Hospital Stamp/Identifier:] _________