Statement of Understanding

Adult Consent Form


I understand that the staff of Refresh Christian Marriage Counseling and those associated with them are not licensed mental health counselors, therapists, medical or psychological practitioners. I understand that Refresh Christian Marriage Counseling staff offers counseling with a biblical value base. The counselors are board certified with the International Board of Christian Care and with the American Association of Christian Counselors. 

I understand that my participation in the counseling process is voluntary and I am free to discontinue attendance at any time. I understand that there is a $90.00 charge for the 1 ½ hr. intake session. I also understand that for second and subsequent sessions, there will be a $120.00 charge per hourly session for couple-to-couple sessions, and $75.00 charge for individual sessions, to help support Refresh Christian Marriage Counseling. Since Refresh Christian Marriage Counseling is a 501c3 the charge can be counted as a charitable donation by the client. Accepted methods of payment are check, cash, or major credit cards (Visa, MasterCard, American Express, and Discover Payment is expected at the time services are rendered. There will be a $50.00 cancellation fee for any appointment that is cancelled within 24 hours of session.

I understand that after the initial intake session, my counselor will commit to several weeks of brief therapy format to address the issues for which I have sought counseling. After the format has concluded, a re-evaluation will be made concerning future counseling sessions. I understand that the information I disclose in counseling is confidential. Confidentiality is assured unless there is reason to suspect that a child under the age of 18 or an adult over the age 65 is endangered by abuse or I am a danger to myself or others. I understand that I may ask for clarification of any part of this statement.

 

Signature
Date
 
 
 
Street Address
City
 
 
State
Zip Code
 
 
Home Phone
Work Phone
 
 
Email Address
 
 
 
Gender
Date of Birth
Age
 
 Marital Status
      
 
 Names and Ages of Children
 
 
 
 
 Education (Check All That Apply)
 
 
 
 Highest Degree Completed
 
 
Have you had any psychotherapy or counseling previously?
Are you currently taking medication prescribed by a doctor?
 
Are you currently taking medication prescribed by a psychiatrist?
Have you used drugs for other than medical purposes?
 
Have you ever been arrested?
Outcome?
 

In The Washington Times, December 23, 2012 reported that 84% of the Adults in the United States claim to hold some type of religious faith.

 Do you claim to hold some type of religious faith?
 
 
If yes, please explain:
 

 

Emotional History

 Traumatic Experience
 
 
 
 Briefly Describe
 
 Emotional Problems, Conflicts and Conditions:
 
 
 
 
  Briefly Describe
 
 
 Excessive or Abnormal Problems with: (check all that apply)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Briefly Explain
 
 Destructive Behaviors
 
 
 
 
 
 
 
 
 
 
 

 Basic Problem Identification

 
 What is the problem/issue that brings you here? (please be very specific)
 
 
 What have you done about it?
 
 
 
  What do you seek from this counseling?
 
 
 What circumstances led to your coming here at this point in time?
 
 
 Is there any other information that you think your counselor should know?