Randolph Walters & Associates, LLC

OUR AGREEMENT

I, the client (or his or her parent or guardian) understands I have the right not to sign this form. I understand I can choose to discuss my concerns with you, the therapist, before I start (or the client starts) formal therapy. I also understand that any of the points mentioned in the brochure can be discussed and maybe open to change. If at any time during the course of therapy I have questions about any of the subjects discussed I this brochure, I can talk with you about them, and you will do your best to answer them.

I understand that after therapy begins, I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending therapy with you.

I have read, or have had read to me, the issues and points in the brochure I did not understand, and have had my questions if any, fully answered. I agree to act according to the points covered in the brochure. I hereby agree to enter into therapy with you (to have the client enter therapy) and to cooperate fully and to the best of my ability, as shown by my signature here.

________________________________________________ __________________

Signature of client (or person acting for client) Date

Relationship to client ____________________________________

EMERGENCY PLAN

If there is an emergency during our work together, or I become concerned about your personal safety, I am required by law and by the rules of my profession to contact someone close to you, perhaps a spouse, relative or close friend. I am also required to consult this person, or the authorities, if I become concerned about your harming someone else. Please complete the section below about your chosen contact person.

Name: _________________________________________________________

Address: _______________________________________________________

Phone: _________________________________________________________

Relationship to you: ______________________________________________

Name: _________________________________________________________

Address: _______________________________________________________

Phone: _________________________________________________________

Relationship to you: ______________________________________________

Name: _________________________________________________________

Address: _______________________________________________________

Phone: _________________________________________________________

Relationship to you: ______________________________________________

I, the therapist, have met with this client (and/or his or her parent or guardian) and have

informed him or her of the issues raised in the brochure. I have responded to all his or her questions. I believe this person fully understands the issues, and I find no reason to

believe this person is not fully competent to give informed consent to treatment. I agree

to enter into therapy with the client, as shown by my signature here.

______________________________________________ ______________________

Signature of Therapist Date

I appreciate the opportunity you have given me to be of professional service to you, and look forward to a successful relationship with you.

__ copy accepted by client

__ copy kept by therapist