Consent form

I _____________________________ hereby authorize _____________________________ (therapist)

of _____________________________ (city/state) to release any and all information contained

in the record of _____________________________ (patient’s name) to Evergreen Psychotherapy Center for professional use only.

This consent will expire on _____________________________ (mm/dd/yyyy).

Signed: _____________________________

Relationship to patient: _____________________________ (parent, self, etc.)

Witness: _____________________________

Date: _____________________________


Credit card type (Visa or MasterCard):

Credit card number:

Expiration date:

Name as it appears on the credit card:

Upcoming Webinars

Certification Training in Trauma and Attachment Therapy with Children, Adults, Couples, and Families
6 sessions: June 1, July 6, August 3, September 7, October 5, November 2
9 a.m. (MST)
Register Here