I understand that I can withdraw my consent to treatment at any time. I have had explained to me
and understand my confidentiality rights as it pertains to my child and disclosure of their
treatment information. I understand that some services may be provided by a Behavioral Health
Technician or unlicensed professional who may be working toward graduate degrees in Psychology,
Social Work, Marriage and Family Therapy, Nursing and/or Psychiatry and/or licensure under the
direction of supervising clinical staff. Other conditions of treatment such as the risks, benefits, and alternatives to the proposed treatment have been explained to me to my satisfaction.