Informed Consent for Website 3-24-20
6300 University Avenue
Suite 125
Middleton, WI 53562
(P) 608-237-8000
(F) 608-237-8005
Client name: _________________________________________
Consistent with HFS 94, Wisconsin Administrative Code, Midwest Center for Psychotherapy
and Sex Therapy wants you to be aware of your rights as a client and ask for your informed
consent to receive treatment. You have also been given information about rights to privacy.
Our grievance procedure is available on request.
The following are general points of information about the therapy process:
The purpose of therapy is to help alleviate the problems and symptoms with which you
During therapy you and your therapist will discuss the problems you have
Any potential side effects from therapy will be discussed with you.
Your therapist will suggest alternative treatment modes and assist in referrals
when appropriate and necessary.
The possible consequences of not receiving therapy or of prematurely ending therapy
can be discussed.
The content of all sessions will be held confidential and can be disclosed outside the clinic
only with your signed approval unless a specific statutory exception applies or a duty to
warn exists. On occasion your therapist may consult with other therapists within the clinic.
If you are being seen as part of a couple or family, there is the possibility that
information from the chart will not be released unless all adult members sign the
appropriate release forms.
Your signature below indicates that you are giving consent to participate in therapy
sessions and that you understand your rights.
This consent will be valid for 15 months. You have the right to withdraw informed consent
at any time. The request must be in writing.
Midwest Center for Psychotherapy and Sex Therapy maintains the right to involuntarily
discharge a client from therapy under the Involuntary Termination Policy.
Please ask your therapist if you have any specific questions.
I have read the above information and have been notified of my rights and the grievance
procedure available to me. I hereby give my informed consent to receive treatment.
Client Signature_____________________________________ Date ____________
Guardian* (where applicable) __________________________Date ____________
Print guardian name__________________________________________
*Guardian means the parent, or legal custodian of a minor client and /or any person
authorized by the client (this authorization must be in writing, witnessed and dated).