CONSENT INFORMATION FOR COUNSELING

Your decision to begin counseling is an important one and you may have
questions. Please read the following information and feel free to ask
questions at any time.
Confidentiality: The information you share during your counseling
appointments will be held in strictest confidentiality. No information will be
released without your permission. The right to confidentiality is limited by
law as follows: a) if you threaten bodily harm or death to yourself, b) if you
reveal information concerning child/elderly abuse or neglect, c) if you reveal
contemplation or commission of a crime or a seriously harmful act; d) if a
court order is given.
Fees: The fee is $75 and is due at time of service. This covers a one hour
session. It is a per session charge (not per person). Incidental phone calls
will not be subject to charge, but a consultation call will be billed as an
appointment.
Cancellations: Please show the courtesy of giving as much notice as
possible if you need to miss your scheduled appointment.
Your signature represents your understanding of the above information and
your consent to the counseling process.
Signature__________________________________Date______________
As a legal guardian, your signature authorizes counseling services for the
minor listed below.
Minors Name_______________________________Date______________
Parent/Guardian_____________________________Date______________