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CONSENT FOR TREATMENT

I voluntarily agree to receive a mental health and medical health assessment, substance use disorder treatment, co-occurring disorders treatment, and discharge/aftercare planning by the staff of PathLight Counseling to take place primarily on the grounds of the facility located at 4390 Earney Rd, Suite 140, Woodstock, GA 30188.

I understand and agree that I will participate in my treatment plan, and that I may discontinue treatment and/or withdraw my consent for treatment at any time.

NOTE: All information developed during the course of my treatment is Protected Health Information as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule. PathLight Counseling is a covered entity of this rule.

I have read this Notice on the date indicated below.

May 6, 2025

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