"I am responsible for my own well-being, my own happiness. The choices and decisions I make regarding my life directly influence the quality of my days."

- Kathleen Andrus

Client Signature to Informed Agreement to Therapy

I have reviewed the information in this agreement

I understand and I am in agreement with the above stated conditions.

I may see my confidential record from art therapy sessions at any time for so long as it exists.

If I participate in group therapy, I pledge to keep artwork and discussions of others in my art therapy group(s) confidential.

I have received and understand Monica Gobournes’ Professional disclosure statement

All of my questions regarding this consent and art therapy have been fully answered to my satisfaction.


My signature below indicates that I understand and agree to the above statements.



Art Therapy Client name (print): _________________________


Signature: __________________________________


Witness/Guardian/Carer name (print): _________________________


Signature: __________________________________



Art Therapist name:  MONICA GOBOURNE


Signature: _________________________________