CONSENT FOR COUNSELING SERVICES

I am voluntarily seeking services which may include: an initial assessment, counseling or coaching.

I am aware that:

• The first four sessions are full sessions in the office.
• No promises or guarantees shall given to me concerning these services.
• The goal plan shall be developed with my understanding and approval.
• Termination is usually an agreement between the therapist/counselor and myself. Termination may be initiated by the therapist/counselor for any inappropriate communication.
• It may be inappropriate to conduct phone sessions or email follow up at my place of employment.

I agree to:

• Pay my fee of $85.00 per hour at the time of the appointment.
• Pay a no show/late cancellation fee of $85.00.
• Keep my scheduled appointments or provide 24 hour notice of a cancellation.
• Be responsible for maintaining a secure computer system.

We accept: