Consent for Treatment

Authorization For Voluntary Treatment

I authorize Tony Himes to administer such treatment as is necessary while I and/or my child are receiving services. I understand that this care is under the direction of the therapist. I understand that I will be informed of the nature of the treatment and the expected consequences, risks, and benefits therein. I understand that I may withdraw or modify my consent to treatment at any time in writing.

I give consent for my child, to receive individual, family, or group counseling services from Tony Himes. I understand that the therapeutic process is a cooperative effort requiring a sense of commitment, belief, and harmony among all parties. I understand that information my child discloses to his/her counselor is confidential except when a Release of Information has been signed, or when a report of suspected child abuse or threatened harm to oneself or others has been made. I also understand that family counseling may be recommended and I agree to participate in such if appropriate.

The client/guardian may at any time decline counseling services by notifying the therapist. I understand that therapy may be terminated by the therapist based upon issues of safety to her/himself, or the client/guardian refusal to follow recommendations for their own protection or well being.

The client/family will at all times be treated with respect, be provided therapeutic services befitting difficulties presented, be informed of steps in the therapeutic process, be given the opportunity to actively participate in decisions regarding their care, and/or be referred to further or other services. I understand that upsetting material may be addressed, that the length of therapy is dependent on numerous factors, and that while every effort will be made to resolve issues and promote growth in a timely manner, there can be no guarantee as to the benefit or progress for each individual client.

Release of information

Specific authorization will be required for release of information.

Personal Valuables

I agree that Tony Himes will not be held liable for the loss or damage to any money or personal valuables in my possession while receiving outpatient services.

Parental Consent

I understand that my personal concerns about the services, the well being of my child, and the fees are welcomed at any time. I am responsible for communicating such concerns directly to Tony Himes. I understand the contents of this form and consent to treatment by Tony Himes.

  • Individuality is all
  • If you don’t do conflict you do alienation
  • It’s complex and trivial
  • You can ask for everything
  • I find myself in my vulnerability
  • Exceptional experience is crucial
  • Willing to have the wound of Love
  • Tap into the flow of your awareness
  • It’s only intensity


(928) 848-1111


3259 N. Wisdom Way
Prescott, AZ 86305