Intern Informed Consent

Informed Consent for Dr. Cy’Tique Davis

*General Information*
This Informed Consent document supplements the regular informed consent you have already been given by this treatment facility. You are receiving therapeutic services from a therapist who is currently enrolled in a marriage and family therapy training program at Northcentral University (NCU). NCU is an education and research institution and provides both standard and advanced education and training in marriage and family therapy (MFT).

*Confidentiality*
Your case records will be kept confidential and private unless disclosure is authorized or required by law. Within the limits of this confidentiality agreement, your therapist may discuss and review your case information with a local supervisor, and with a supervising faculty member and a supervision group at Northcentral University. All NCU supervisors and participants in the supervision group have committed to uphold the MFT professional standard of confidentiality. Additionally, every possible effort is taken by your therapist to limit the disclosure of any identifying information. All supervisors and therapists who are granted access to this confidential material are bound by the same ethical standards of confidentiality as your primary therapist. Your treatment facility’s primary informed consent will provide you with information about other limits to confidentiality as set forth in your state laws.

*Consent for Working with an NCU Intern*
I voluntarily consent to receive therapy services or have my child accept services provided by:
CyTique T. Davis, MFT-Intern of Lifestyle Therapy and Coaching.
• I understand that my therapist is a marriage and family therapist in training under the supervision of clinical faculty.
• I understand that Northcentral University is a teaching program.
• I understand the purpose and potential benefit supervision of my therapy services, and I voluntarily consent and agree
to their use.
• I understand that this consent to services will be valid and remain in effect as long as I attend therapy sessions unless
revoked by me in writing, with written notice provided to my therapist.
• If I have any questions or concerns now or in the future, I understand that I should consult with my therapist or the MFT
Director of Clinical Training at NCU (clinical@ncu.edu).
Consent to Record
Our goal is to provide guidance and support through supervision of all trainees as they offer consistent and professionally competent services for their clients. To accomplish this goal, we routinely use video or audio recording and direct supervision through secure online video conferencing, including review of video/audio recordings of therapy sessions. Video/audio recording, supervision, and consultation are standard practices in MFT training and education throughout the profession, and are used to assist the therapist in improving skills and in planning for future sessions. Just as importantly, these tools help us, the therapist’s clinical supervisors, ensure that you are receiving the best possible care. Please initial next to the statement that reflects your consent status.
_____ I consent to be video/audio recorded for my therapist’s training purposes.
_____ I do NOT consent to be video/audio recorded for my therapist’s training purposes.

I certify that this form, including the statements on the limits of confidentiality, has been fully explained to me, that I have read it or had it read to me, and that I understand its contents. I certify that I have legal authority to give consent for the treatment of all minor children that are included in therapy.
Date
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Signature of Client or Other Legally Authorized Person
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Signature of Client or Other Legally Authorized Person
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Signature of Client or Other Legally Authorized Person
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Signature of Client or Other Legally Authorized Person
Print Name and Relationship to Client Print Name and Relationship to Client Print Name and Relationship to Client Print Name and Relationship to Client Print Name and Relationship to Client