MS, LMFT, BCC
Board Certified Life Coach
FEES FOR SERVICES
(Payment information appears at the end of this form.)
Note: If necessary, travel expenditures will be charged separately.
NOTE: Coaching sessions must be used within one year of the date of purchase.
ALL SESSIONS ARE NON-TRANSFERABLE.
If you fail to cancel a scheduled appointment, this time cannot be used for another client and you will be billed for the entire cost of your missed appointment. A full session is charged for missed appointments or cancellations with less than 24 hour notice unless due to illness or emergency. Thank you for your cooperation in this matter.
LIMITS OF CONFIDENTIALITY
Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:
Duty to Warn and Protect / when a client discloses intentions or a plan to harm another person, the mental health professional is required
to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide,
the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.
Abuse of Children and Vulnerable Adults / if a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to
report this information to the appropriate social service and/or legal authorities.
Prenatal Exposure to Controlled Substances / mental health care professional are required to report admitted prenatal exposure to controlled substances that are potentially harmful.
Minors/Guardianship / parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.
I agree to the above limits of confidentiality and understand their meanings and ramifications.
Please provide the following information and answer the questions below. Please note: Information you provide here is protected as confidential information.
GENERAL HEALTH AND MENTAL HEALTH INFORMATION
FAMILY MENTAL HEALTH HISTORY
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