I understand that I have the right to decide not to enter therapy (although depending on my situation, there may be legal consequences) and to terminate therapy at any time.

I understand that I have the right to a safe environment during therapy, free from physical, sexual, and emotional abuse. Any abuse should immediately be reported to the grievance board.

I understand that I will not be discriminated against due to race, sex, religious beliefs, socio- economic status, or past criminal convictions. 1 understand that I will not he discriminated against nor denied treatment for physical, psychological, or emotional handicaps. If the facility is not equipped for my specific handicap, due to limited resources or staff limitations, I will he referred to an agency that is better equipped to address my needs.

I have the right to know information about my treatment, methods, potential risks and benefits, progress, fees, length of sessions, and the duration of treatment.

I understand that my right to confidentiality will be protected, and information regarding my treatment will not be disclosed to any person or agency without my written permission, except under circumstances where the law requires such information to be disclosed. I have the right to know the limits of confidentiality, the situations in which the therapist/agency is required to disclose such information to outside agencies, and the types of information that must be disclosed.

I understand that I have the right to information about the professional capabilities and limitations of any clinician(s) involved in my therapy, including their certification/licensure, education and training, experience, specialization, and supervision.

It is my responsibility to notify Adult/Youth Services, LLC. if I am going to be late or miss a session. I understand that if I do not notify the staff before my session, I will be charged $10.00 per each unexcused absence. After two unexcused absences, I understand that Adult/Youth Services, LLC. has the right to report my non-compliance to the courts.

It is my responsibility to pay all tees at or before the time of service. I understand services will not be rendered. I also understand any outstanding unpaid balances over 30 days will be reported to an outside collection agency.

It is my responsibility to provide necessary information, including name of person/division and case number, to Adult/Youth Services, LLC. if I want to notify the Courts, Attorney, etc. of my enrollment, progress, and/or completion status.

It is my responsibility to protect the identities and disclosure of members in group sessions by keeping everything discussed absolutely confidential and within the agency.