*Please note there will be additional costs involved for any reports or appearances made in court.
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 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.., email, skype, texting, or phone sessions. Any electronic communication cannot guarantee security and\or confidentiality.
When emailing a counselor please send the email to the Christian Counseling Center and not to your counselor’s personal email. Please use email@example.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.