By agreeing to receive the previously identified services, you are certifying that you have received guidance regarding the following:

1. That you may withdraw from the previously identified services at any moment with no penalty. If this is the case, you must request it in writing.
2. That all the information disclosed during the treatment will be strictly confidential in nature, but that this confidentiality may be disregarded if there is a risk to your life, your physical or emotional safety, or property, or that of your child or of others.
3. That you must not hold personal or social meetings with the student in clinical training.
4. That your relationship with the student in clinical training is strictly and exclusively professional in nature.
5. That you understand that the student in clinical training is under the oversight of a supervisor with a professional license to practice the occupation in Florida, and that the case will be discussed with this person.
6. That you agree to receive the services under the conditions previously described, and you certify with your signature that you have received an explanation of the nature of the services to be offered in a simple and natural language, including risks, materials, benefits and available alternatives, as well as the risks involved in not receiving the service.