Ahwatukee Psychological Services

Permission is hereby granted to Dr. Astrid Heathcote, Psy.D., to provide psychological services that may include: assessment and diagnosis, treatment planning, individual- and/or family therapy to:

Patient Name:

Date of Birth:

All information gathered is confidential except when information must be relased in cases of medical emergencies, homocidal and/or suicidal ideation, abuse or  neglect, court order, billing requirements, or whenever required by law. Records will be maintained as required by the American Psychological Association (APA) and the Arizona Board of Psychologist Examiners and relevant state laws.

The undersigned agree to participate in treatment planning. Consent can be revoked by the patient or guardian at any time.

 Patient Print________________  Sign.____________Date___________

Guardian Print_______________   Sign.____________Date___________