INTAKE AND DISCLOSURE FORM

This form gives us necessary information to help you best. It also is a legal document that you will e-sign upon completion; it will contain a disclosure at the end. Please NOTE that all fields with an asterix are mandatory and you will NOT be able to submit the form if you leave a required field blank. In required fields please put N/A if it's not applicable. Thank you!

I understand that Pastoral Counseling is not a state regulated or state licensed profession. Life choices are my sole responsibility... my counselor will not tell me what to do or not to do directly, unless what is being expressed to my counselor is something that would cause harm to myself, and/or other people. I understand that I may be referred to another professional in addition fo or replacement of my treatment with my counselor. All communication is confidential unless as expressed above, there is danger to myself and others. I will be presented with the option to sign a HIPPA form to allow my counselor to speak with other possible certain individuals.

FINANCIAL TERMS. I understand that my counselor does not accept insurance and that payment for services is solely my responsibility. I understand that if I cancel an appointment within 48 hours I will be charged for the appointment. I will be able to reschedule my appointment with no additional charge, however there are no refunds.

Appointment costs are $130 per hour. APS testing is $75 per test.