By signing this form, I acknowledge that MSM Counselling Services and MSM informs the risks, benefits, purposes, and alternatives of psychotherapy. MSM certifies that I consent to receive mental health treatment from MSM. 

Patient comprehends that may voluntarily discontinue treatment at any time.MSM reserves the right to terminate treatment at any time where its deemed that clinical judgement to treatment is not progressing.MSM will make reasonable efforts to  make referral to other  treatment facilities, and agrees to consult with future providers if there is a  request  in writing.

MSM acknowledges that we have discussed the  limits of confidentiality according to the  State laws of Wisconsin and other federal regulations  including  self  harm tendencies ,abuse  and other legal proceedings. There is consent that  cell phones and emailcommunications  may lack full confidentiality. I grant consent that I have been given written information on privacy practices of MSM office and my rights regarding protected health care information according to federal HIPAA regulations.

MSM doesnot have  emergency services , please call  911 .In the event of session cancellation,MSM requires 48 hour notice