Consent to Evaluation & Treatment for Adults

Fill out the Consent to Evaluation & Treatment for Adults form below and submit it to our office once fully complete. If you would rather print a copy of the form, fill it out, and bring it to the office, you can click the button below to download a copy of this form.

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Your treatment and/or evaluation can promise great benefit and also comes with some risks. Risks can include experiencing uncomfortable levels of emotion such as sadness, guilt, anxiety or anger; and recalling and discussing unpleasant life experiences can be distressing. Jillian DePaul, Ph.D. will discuss with you the benefits and risks of the treatments and/or evaluation process in your particular case. Though there are no guarantees, these services have been shown to benefit people in various ways.

This consent will remain in effect through completion of your treatment with Jillian DePaul, Ph.D. You have the right to revoke your consent to treatment at any time. Should you choose to do so, we ask that you do so in writing. Notice of revocation of consent will be considered effective on the date Jillian DePaul, Ph.D. receives your revocation. Revocation of consent will necessarily result in termination of treatment.

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