Steven D. Graham, PhD, DMin 

Steven D. Graham, PhD, DMin 


I, _____________________________________authorize and request that Steven D. Graham, Ph.D., D.Min., provide psychological evaluations, treatment, and/or diagnostic procedures which now or during the course of my care as a patient are advisable.  The frequency and type of treatment will be decided between Dr. Graham and me.

I understand that the purpose of these procedures will be explained to me, and be subject to my verbal agreement.

I understand that there is an expectation that I will benefit from psychotherapy but there is no guarantee that this will occur. 

I understand that maximum benefit will occur with consistent attendance, and that at times I may feel conflicted about my therapy as the process can sometimes be uncomfortable.

I have been informed and understand the limits of confidentiality, that by law, the therapist must report to the appropriate authorities any suspected child abuse or any serious threat of harm to myself or another person.

I have read and fully understand the Consent for Treatment form.  By signing below, I also acknowledge that I have received a copy of the Notice of Privacy Practices. 


Date:  __________           Patient Signature:  __________________________________ 

Date:  __________           Therapist Signature:  ________________________________