ConsentForTreatment .pdf

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Jana Mulvaney, Ph.D.

Donna McCann, MA, MFTI

PSY # 21395

Intern # 81128

Clinical Psychologist/Supervisor

Marriage and Family Therapist

Marriage and Family Therapist

Intern

Consent  for  Treatment  with  a  Marriage  and  Family  Therapist  Intern  
Donna McCann is a registered Marriage and Family Therapist Intern, a term established by the
Board of Behavioral Sciences for unlicensed therapists with a Master’s Degree or higher. A
Marriage and Family Therapist Intern may provide therapy under supervision of a licensed
Psychologist or Marriage and Family Therapist who provides supervision, guidance, and has full
access to client’s records. A Marriage and Family Therapist Interns is an employee of the
supervisor, to whom they are registered.
Donna McCann has a Master of Arts in Clinical Psychology, with a specialization in
Psychological Trauma, and is currently registered (MFTI # 81128) to Jana Mulvaney, PhD (Psy
# 21395). Due to the supervisory relationship, your personal information may be disclosed to Dr.
Jana Mulvaney for the purpose of providing you with optimal treatment. Any questions or
concerns may be directed to Dr. McCann or Dr. Jana Mulvaney at (310) 392-1819.
I have read the above agreement and information carefully. I have asked Dr. McCann or Jana
Mulvaney, PhD any questions I had/have. I understand them, agree to comply with them, and
consent to treatment.

_________________________

_____________________

____________

Client Name (print)

Client Signature

Date

_________________________

______________________

____________

Provider Name (print)

Provider Signature

Date

_______________________

____________

Supervisor Signature


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