I agree to and consent to participate in psychological treatment (Patient Name) Services rendered by Champion Psychological Services, LLC a behavioral health provider. I understand that I am agreeing only to those services that my psychologist is qualified to provide given their license, certifications, and training. No promises can be made as to the results of treatment, or any procedures provided by my treating psychologist.

Federal law permits Champion Psychological Services, LLC to disclose information in the following circumstances without your written permission:

• If you make a serious threat to harm yourself,or another person. The law requires that Champion Psychological Services, LLC protects you, and that other person.

• The law requires Champion Psychological Services to reports suspected child/elder abuse, or neglect to authorities. If you have questions regarding your treatment, or our policies, please feel free to discuss with your psychologist. I hereby acknowledge that I have read (or have had read to me the information) above, and I understand and give my consent to participate in treatment with Champion Psychological Services, LLC.

Patient Sign & Date
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