Consent form

I _____________________________ hereby authorize _____________________________ (therapist)

of _____________________________ (city/state) to release any and all information contained

in the record of _____________________________ (patient’s name) to Evergreen Psychotherapy Center for professional use only.

This consent will expire on _____________________________ (mm/dd/yyyy).

Signed: _____________________________

Relationship to patient: _____________________________ (parent, self, etc.)

Witness: _____________________________

Date: _____________________________

 

Credit card type (Visa or MasterCard):

Credit card number:

Expiration date:

Name as it appears on the credit card:

Upcoming Webinars

Adult Attachment Styles (FREE WEBINAR)
Tues., Jan. 25
12 p.m. (MST)
Register at Raise the Future

Trauma and Attachment Therapy: A Family Systems Approach
Thurs, March 10
8 a.m. (MST)
Register at Nefesh.org

Attachment and Trauma-Focused Therapy with Couples
Dates TBD
Register at dianepooleheller.com

What is attachment?

It is the deep and enduring connection established between a child and caregiver in the first several years of life. However, more and more children are failing to develop secure attachments to loving, protective caregivers. These children are left without the most important foundation for healthy development and are at risk for:
  • low self-esteem
  • lack of self-control
  • antisocial attitudes and behaviors
  • aggression and violence
  • lack of empathy, compassion and remorse
Read more.

Recommended reading

These books and journal articles explain the most important aspects of attachment in adults and children, child maltreatment, treatment approaches, parenting and related social issues.