Phone Counseling

The following is needed to best help you. Please copy and past this form on to a word document, then print it . Clearly print your response to each question. On your first intake call you will be asked to fax the form to us. This will help save time in your first session. All personal information and Case records are strictly confidential.

Name___________________

Date of Birth______________

Address________________________ City________ Zip_______

Home Phone________________
(may we leave a message? YES/NO)

Cell Phone__________________

Gender F___   M____

Email Address___________________

Level of completed education________________

Ethnicity: __________________

Relashionship Status: _________________

How soon would you like your counseling session?

As soon as possible
Within 48 hours
Within 72 hours

Please describe the issue for which you are seeking counseling. Include any detail that comes to mind. Include a time frame so that I know how long your issue has been affecting you. ___________________________________________________

___________________________________________________

___________________________________________________

Define a counseling/coaching goal. What is the MOST IMPORTANT thing you would like to achieve through phone counseling.

____________________________________________________

____________________________________________________

____________________________________________________

All clients engaging in Phone counseling, must be 18 years of age or older.

Privacy & Confidentiality:
All communications are conducted in a private setting and held in strict confidence. Information shared can not be released by the counselor to anyone except for the follow exceptions:   (1) A client reveals the thoughts or plans to harm themselves or others. (2) Reveals any situation that may be considered abuse or danger to a child or elderly individual. (3) With clients written consent. If you have any concerns regarding the first two points than it would be advised that on intake you request Anonymity: so when you enter into a counseling session, only your user name will be provided to the Counselor – no other information will be provided to the Counselor .

Anonymity: YES/NO

if yes, user name:_______________

Security of Telephone Counseling:
The telephone will be used to collect personal information.Telephone counseling services are provide utilizing standard telephone equipment and services.   Client agrees to provide counselor with the telephone number they wish to utilize for this service. The call will be made at the scheduled session time. Client holds responsibility for establishing a comfortable environment for themselves, without risk of interruptions or distractions. Client is also asked to disengage telephone features such as call waiting and call block for the session time.

Limitations Of Services:

	Telephone Counseling may not be the most appropriate modes of counseling services for certain situations or individual issues.
	Clients in an emergency situation or crisis, and/or experiencing thoughts of suicide, self harm or harming others, must call 911 immediately.

	Before entering into a counseling relationship, client agrees to a brief evaluation of needs, and will enter into the agreed mode of counseling services at their own risk.

Fee Agreement:
Fees are to be paid prior to services provided. Only Credit cards will be accepted. My signature below authorizes EEE to take payments from my credit card.

MasterCard/Visa

Name on credit card: _________________

Number on card: _________________________________

Expiration Date ______________________

CVC (3 additional digits at the back of your card) ___________

Billing Address ________________________ City:___________

State:_______________ Zip:_______________

Signature________________ Date: ___________

Missed or Canceled Appointments:

Client agrees to cancel appointments at least 24 hours in advance. Clients not giving proper cancellation notice, will be charged a $50.00 fee for each missed appointment.

Fee Refunds:
Refunds will be given for the following reasons:

	Client gives at least 24 hours notice to cancel prepaid appointment.
	Counselor fails to keep the appointment.

Equipment Failure:
One of the disadvantages of utilizing telephone and computer/Internet technology is the unforeseen equipment failure. Should client or counselor lose connection during an online session, both will attempt to reconnect immediately. No charges are accrued during this reconnect time. Should reconnection not be immediately possible, the time remaining for your session will be credited to another session time. Counselor does not accept responsibility for any technical difficulties that could occur. Should technical failure prohibit a session, alternative arrangements or another scheduled session will be made.

Referrals for Additional Services:
Occasionally the client may need additional services not offered by counselor. Counselor will provide client with referrals if possible. However, client holds the responsibility and risk for contacting and accepting these services and their outcomes.

Termination of Services:
Client or counselor may choose to terminate the counseling relationship at any time. The party choosing to terminate the relationship, agrees to contact the other party through e-mail or written letter, with reasons for termination. Client may choose to terminate the counseling relationship at anytime. Counselor may terminate relationship if they feel the client has reached their goals, the client is not progressing under the counselors care, or the counselor is not qualified to provide the services needed at this time. Counselor agrees to provide client with referrals for more appropriate services should this be needed.

I ______________________ agree to all the above terms.

Signature________________ Date: ___________