Art Therapy Informed Consent

Art Therapy Informed Consent

Provided by: Wellness Grove
Client Legal Name*

First NameMiddle NameLast Name
Client Preferred Name
Client Date of Birth*

MonthDayYear
Last 4 of SS# for Client*
Client Age
Current Date

MonthDayYear
If the client is under 18 years old you will be required to describe your relationship to the client at the end of the informed consent form.
Email Address*

Confirmation Emailexample@example.com

Acknowledge & Sign
I have read and understand the information provided within this Informed Consent Form. I understand that I will have an opportunity to discuss the terms of this consent with my clinician at the start of my counseling session. I acknowledge and agree to present all of my questions to my clinician, if any, and to not proceed with my counseling session until all of my questions have been answered to my satisfaction. I understand that by continuing my participation in the counseling session I am asserting my understanding and agreement to the information provided in this consent form.

I hereby give my informed consent to allow any and all Art Therapy works to be shared internally with any active Wellness Grove staff member or with those involved in the direct supervision of counseling services for either myself or minor client under the terms described herein with Wellness Grove.
By signing this form electronically and clicking on "Sign & Submit", you are certifying your agreement to the informed consent for Wellness Grove Art Therapy counseling services. Please note that an e-signature is the electronic equivalent of a hand-written (pen-and-paper) signature.*

Clear
Input Legal Name*
Client or Parent/Guardian/Legal Representative
Date*

MonthDayYear
If Parent/Guardian/Legal Representative, please describe your relationship to the client
Should be Empty:

Acknowledge & Sign