Consent to Treatment Form

Consent to Treatment
Please sign below, indicating that you have read and understand this Consent to
Treatment form, and agree to abide by treatment policies.

1. Psychotherapy has both benefits and risks. Risks sometimes include experiencing uncomfortable
levels of feelings like sadness, guilt, anxiety, anger, frustration, loneliness and helplessness.
Psychotherapy often requires recalling unpleasant aspects of your history. Psychotherapy also has been shown to have benefits for people who undertake it. It often leads to a significant reduction of feelings of
distress, and to self-awareness, better relationships, and to resolution of specific problems.

2. I authorize and request Dr. Winston Wilde to carry out psychological examinations, treatments, and/or diagnostic procedures which now or during the course of my care as a patient are advisable. I understand that the purpose of these procedures will be explained to me and are subject to my agreement.

3. Type of psychotherapy. Psychological interventions by Dr. Wilde are guided by psychoanalytic and
psychodynamic principles. This means that psychotherapy may examine your past and its connection to present difficulties, your feelings and thoughts, and the relationships in your life including the developing
relationship with your therapist. There are many other forms of therapy available which Dr. Wilde may employ if appropriate. These may include cognitive and behavioral therapies which tend to focus more on
symptom reduction and less on an understanding of present and past relationships, and an existential or narrative approach with more of a here-and-now focus.

4. Length of treatment. It is difficult to estimate the length of psychological treatment with precision. In general, treatment will be available to you for as long as you and your therapist agree is necessary. If Dr. Wilde believes that treatment is not helping you, after discussing this with you and explaining options to you, treatment may be discontinued.

5. My decision to undergo psychotherapy is voluntary. I understand that I am free to discontinue at any time.

I have read and understand this consent form.