HOLISTIC HEALTH

GUILLERMO PARRA MARTINEZ

PSYCHOLOGY – ALTERNATIVE THERAPIES
Memopar2000@yahoo.com Mobile 3103220227

Informed consent
General data
Name: DC Age
Birth: City:
Gender: Civil status:
Address and telephone Neighborhood/city
Occupation:
Place of intervention Date:
Applicant: No. of process:
( Only applies to procedures requested by a (Applies to procedures within the
third party). framework of legal psychology).

I certify that I have received and understood that the information received by the psychologist is
confidential and that it may be revealed if during the evaluation or treatment, the psychologist
clearly detects that there is obvious harm to me or third parties (In the procedures related to
forensic psychology, it must be specified that the information given to the psychologist will
be condensed into a report that will be delivered to the lawyer and that he will make it public
in the corresponding legal settings). In the case of legal environments, special emphasis will be
placed on non-self-incrimination and non-observance of professional secrecy. I was told that the
procedure to follow is ( specify in a clear and understandable manner the procedure to be
followed. If necessary, before the therapeutic intervention, indicate that an evaluation will be
carried out through the application of tests; These should be listed, clarifying the purpose of
each of them. Likewise, the diagnostic impression will be indicated, if applicable. If the
psychologist has a diagnostic impression in the terms of the DSM or the ICD, even if it is
tentative, and that is given as a consequence of the evaluation, he will let the consultant
know, indicating what type of treatment will be carried out, explaining in what This consists
of: systematic desensitization, cognitive restructuring, social skills and assertive
communication, etc. ) and the possible time the treatment will take. I was also told that I can
revoke consent or terminate the relationship between the psychologist and me at any time, when I
consider it appropriate, without this implying any type of consequence for me.

Once the procedure to be followed has been read and understood, this consent is signed on ------
day of the month ----------- of the year ---------, in the city of----------------.

Signature of the user Signature of the psychologist

DC No. DC No. 80264453
T.P. No. 153899