Consent for Counseling Services

Clients Rights and Responsibilities

As a client you have the right to expect confidentiality and to be treated fairly and courteously. You will not be discriminated against on the basis of race, color, national origin, age, sex, disability, religion or sexual preference.


Client Release

I hereby state that I and/or my child(ren) have come to receive counseling services of my own free will. I understand the decision to continue counseling is completely my own decision.

I hereby release Erica Randolph from any and all claims, demands, or actions for injury sustained by me and/or child (ren) while receiving counseling. Erica Randolph will not be held liable for any sustained injuries.


Responsibilities of Clients

My initial represents a commitment to my responsibilities while receiving services.

_____ I agree not to use violence as a means to deal with my anger.

_____ I agree to inform my therapist if I am not able to attend my therapy session.


Consent for Counseling Services

By signing below I agree to the above information and confirm that I have read and that I understand my rights and responsibilities.

By signing below I consent to the services offered to me by Erica Randolph which include therapy, legal advocacy, play therapy for my child(ren), group therapy, skills and knowledge, educational classes, nutritional classes and children’s activities.


Client Signature:________________________________Date:______________


Witness: _____________________________________ Date:______________




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