Janneta Bohlander & Associates, LLC

Janneta Bohlander, LMFT

83 East Avenue, Suite 208

203-521-0805

Janneta Bohlander, LMFT

CT license number 000955

Tax ID 20-3204106

CONSENT FOR TREATMENT

I/We grant Janneta Bohlander & Associates, LLC my/our medical permission and informed consent
for the mental health evaluation and treatment for:
I/ We understand the therapist may legally speak to another health care provider without prior
consent, but the therapist will not do so unless the situation is an emergency. The following are legal exceptions to the client’s right to confidentiality: If the therapist has good reason to believe that the client will harm another person, she must attempt to inform that person, warn them and contact the police. If the therapist has good reason to believe that the client is abusing or neglecting a child or a vulnerable adult, or if he or she gives the therapist information that someone else is doing this, the therapist must inform Protective Services within 24 hours. If the therapist believes that the client is in imminent danger of harming him or herself she may legally break confidentiality and call the police or a crisis team.
I/ We acknowledge that he or she is responsible for a payment of $ 190 per session. If this is a
I/We understand that if we are unable to attend a session he or she will give 24 hours notice in
advance. If the client does not give 24 hours notice in advance they are responsible for the full session fee.
I/We authorize the release of any medical or other information necessary to process insurance
claims. I also authorize the payment of medical benefits to the undersigned therapist for the services provided.
I/We have read and fully understand this Consent for Treatment form.

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