Form 4. Consent to Treatment

Willow Ann Rose LPC CHT ~ SpiritWell
 PO Box 42114 – Eugene, Oregon 97404
www.spirit-well.com

Phone: (541) 461-5424

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Email: [email protected]

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I consent to and authorize Willow Ann Rose LPC CHT to provide Transpersonal Psychotherapy-Counseling to me. Services may include any of the modalities we have discussed, I have requested, and have agreed to as part of our therapeutic work together.

I attest that I have read through Ms. Rose's Professional Disclosures and discussed with my therapist any questions or concerns. I understand that Ms. Rose welcomes questions and conversations about these disclosures or any other matters at any time during our work together.

I have also reviewed and signed the Financial Agreement and agree and affirm that I am responsible for payment of services rendered to me by Willow Ann Rose LPC CHT.

I affirm that my request for services is voluntary and that I may discontinue at any time. I understand that termination is often an important part of the therapy process, and acknowledge my therapist requests that she will welcome any conversation regarding my choice to end our counseling relationship at any time.

I also understand that Willow Ann Rose LPC, CHT, may choose to discontinue our work together for any of the following reasons:

- I am not consistent in attending scheduled sessions.
- I have not honored our financial agreement and am over three sessions in arrears of payment for my services.
- Alcohol, drug use, or other factors impact my ability to engage in meaningful sessions.
- Ms. Rose believes she lacks the expertise to help me and that another therapist or specific modality will be of more support to my well-being.

Should any of these reasons/concerns occur, I understand that termination by my therapist will always be discussed in advance, and I will be provided with recommendations and referrals to other services.

C. 2014, 2017,2018, 2020 Willow Ann Rose, LPC CHT~SpiritWell