L. Eileen Keller, Ph.D.
Licensed Psychologist, PSY7350
CONSENT TO TREATMENT - ADULT
I understand and consent to the following:
1. I authorize and request my treating provider to carry out psychological treatment.
2. I acknowledge that I am being informed that under California
3. I understand that:
4. My consent is for me and any minor children. Consent is voluntary and, except for Items 2 and 3 (limits on confidentiality) and urgent consultations, I may withdraw my consent to future disclosure at any time by writing a letter to Dr. Keller.
5. I have received a copy of this form.
This consent is in effect for the duration of treatment up to three years.