Co-Parenting Solutions, LLC

248.330.5351 | | 31000 Telegraph Rd., Ste 280, Bingham Farms, MI 48025

Consent for Therapeutic Treatment

Welcome to my practice. This document contains important information about my professional services. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of yours or your child’s Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.


Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you or your child have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as yours or your child’s therapist, have corresponding responsibilities to you. These rights and responsibilities are described below.

Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your or your child’s life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on the part of the client. In order to be most successful, you or your child will have to work on things we discuss outside of sessions.

If you have questions about my procedures, we should discuss them whenever those questions arise. If your doubts
persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.


My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been offered a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.


Your signature indicates that you have read this Agreement, have your questions answered and had the opportunity to read the Notice of Privacy Practices and agree to their terms

Date Signed:
Printed Name: Relationship to Child:  

Revised 12/2019

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Co-Parenting Solutions, LLC
Signature Certificate
Document name: Consent for Therapeutic Treatment
lock iconUnique Document ID: 4033d98b4e514a3ad3484893a095786c23878c0e
Timestamp Audit
July 24, 2020 2:47 pm EDTConsent for Therapeutic Treatment Uploaded by Jordana Wolfson - IP