Adult Client Form

Please fill out the following form if you are an adult client.

Adult Client Form

First Name(Required)

First

Last Name(Required)

First

Sex(Required)

Male

Female

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone Numbers to Contact/Leave Messages:

Primary Phone(Required)

Secondary Phone

Email Address(Required)

Birth Date(Required)

Age(Required)

Marital Status(Required)

Spouse Name(Required)

Do you have a counselor you prefer? If so, whom?(Required)

Insurance

Insurance Co:(Required)

Insured ID:(Required)

Group #:(Required)

Social Security Number of client:(Required)

** If you are not the Primary on the insurance please provide the following information:

Primary’s Full Name:

Primary’s Birth date:

Primary’s Social Security Number:

In a few words, please explain why you have come to the Christian Counseling Center:(Required)

How long has this been a problem for you?(Required)

How have you tried to solve this problem?(Required)

Consent to Treatment

This form is to document that I give my permission and consent to the Christian Counseling Center to provide counseling.

While I expect benefits from this treatment, I fully understand that because of factors beyond our control or other factors, such benefits and particular outcomes cannot be guaranteed. I understand that because of the counseling or therapy, I/he/she/we may experience emotional strains, feel worse during treatment, and make life changes which could be distressing.

I understand that this therapist is not providing an emergency service and I have been informed of whom to call upon in an emergency or during weekend and evening hours. I understand the counselor is a consultant and a professional resource only, whose intervention may be freely accepted or rejected by the client, therefore, decisions made during and after counseling are the responsibility of the client. I understand that regular attendance will produce the maximum benefits but that I am/are free to discontinue treatment at any time. I understand that the client is free to terminate services at any time.

I understand that conversations with the therapist will be confidential except as allowed by the Privacy Policy of the Christian Counseling Center. However, I understand there are limits to confidentiality based on payment methods, wireless and electronic communication that I elect to utilize. I further understand that Florida law requires any therapist who has reasonable cause to suspect child or elder abuse, neglect and abandonment/exploitation to report such knowledge to the appropriate authorities. I also understand that Florida law allows the confidentiality between the therapist and client to be waived when there is a clear and immediate probability of physical harm to the client, to other individuals, or to society and the therapist communicates the information only to the potential victim, appropriate family members, law enforcement or other appropriate authorities.

I understand that I am financially responsible for this treatment and for any portion of the fees not reimbursed or covered by third parties. I also understand that I am expected to pay for the counseling fees at the time of the visit and any arrangement for payments by third parties will be made before the counseling session. I understand that receipts will be provided for at each request.

Cancellation of Appointments
To avoid paying for cancelled appointments, the undersigned agrees to call CCC 24 hours before the date of the appointment. CCC offers the undersigned the option of having a telephone session to avoid having to pay a broken fee. The fee for a broken appointment is the full session rate unless your specific counselor has their own separate broken fee arrangement. After three or more cancellations my counselor has the right to cancel any appointments that may be scheduled out. CCC will notify the client that the appointments will be taken off of the schedule.

No show/ No call will result in an automatic full fee charge for the missed appointment. I understand that my counselor has final say in if a broken fee will still be applied or not.

Social Media Consent Form
Christian Counseling Center cannot guarantee confidentiality when it comes to using social media to connect with your counselor or staff of the Christian Counseling Center. This includes any social media online such as Facebook, twitter, etc. When using any form of virtual telehealth communication, I understand that there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare provider and I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. Telehealth is not an emergency service, and in the event of an emergency, I will call 911.

When emailing a counselor please send the email to the Christian Counseling Center and not to your counselor’s personal email. Please use cccbrandon@aol.com if you wish to send something to your counselor. One of the staff members will then either forward the email to the counselor or print it out for the counselor to view. Please use email only for non-urgent situations. If you do not receive a timely reply, please call the Christian Counseling Center.

Received Notice of Privacy Practices(Required)

I have received the Notice of Privacy Practices of the Christian Counseling Center and I agree to read it and discuss any questions I may have with my therapist. I understand and agree that this consent form will remain valid subsequent to my reading the notice unless I advise otherwise.

Areas of Personal Concern

Please Rate Only the Items You Are Currently Concerned About by Placing a Number in the Box Beside the Concern

1 = Mildly Upsetting, 2 = Moderately Severe, 3 = Very Severe, 4 = Extremely Severe, 5 = Totally Incapacitating

Stress