Consent to Treatment by Postdoctoral Fellow


InMindOut Emotional Wellness Center, LLC is committed to the education and training of future
clinicians in mental health. As such we employ Postdoctoral Fellows on our staff. A Postdoctoral Fellow
is an individual who has completed their doctoral degree in clinical psychology and is pursuing their
doctoral license. The fellow is under the supervision of Dr. Heather Ingram, while engaging with clients
at InMindOut, LLC. As the fellow is unlicensed, we accept an out-of-pocket, slid ing fee scale for clients
seen by the Postdoctoral Fellow.

  • I understand that all terms from the InMindOut Emotional Well ness Center, LLC Psychologist –
    Client Contract apply to sessions with Postdoctoral Fellow.
  • I am willing to receive therapeutic services from the Postdoctoral Fellow.
  • I understand that I can terminate this agreement at anytime.

 

If client is a minor, please have the parent or legal guardian sign this form.

Leave this empty:

InMindOut Emotional Wellness Center https://inmindout.com
Signature Certificate
Document name: Consent to Treatment by Postdoctoral Fellow
Unique Document ID: aa1a01867966ff13c9aadd869db0a13128249515
Timestamp Audit
October 17, 2017 2:49 pm CSTConsent to Treatment by Postdoctoral Fellow Uploaded by Amanda Bergeron Bergeron - amanda.bergeron@inmindout.com IP 23.122.45.227