PLEASE READ ENTIRELY BEFORE SIGNING: I HEREBY AUTHORIZE MITCHELL ROSEN TO TREAT THE ABOVE NAMED PATIENT. I AGREE TO BE FINANCIALLY RESPONSIBLE FOR ALL CHARGES UNLESS OTHERWISE ORDERED. I UNDERSTAND THAT CANCELLATIONS WITH LESS THAN 24 HOURS NOTICE OR NO SHOWS WILL BE CHARGED AT THE FULL FEE AND I WILL BE RESPONSIBLE EVEN IF COUNSELING CHARGES ARE TO BE PAID BY OTHER PARTY. I UNDERSTAND THAT PHONE CONSULTATIONS ARE AVAILABLE AND WILL BE CHARGED AT A PRORATED FEE. I AGREE TO THESE TERMS OF TREATMENT. I AGREE THAT MITCHELL ROSEN SHALL NOT BE CALLED AS A PRECIPIENT WITNESS.