In Take

General Intake Information:
Insurance Authorization and Assignment:

Clients Rights and Responsibilities:

To be an effective consumer of counseling services, it is important that you know about your rights and responsibilities and about our obligations to you.
Please read this statement carefully and discuss any questions you might have with us.

We are dedicated to providing quality counseling, testing, and consulting services. We believe that each client should receive competent, prompt, and respectful services regardless of race, sex, creed, or national origin.
When necessary, we consult with other specialists, and may refer you to additional resources.
When you become a client, you have the right to:
1. Confidentiality . It is our policy to respect you privacy and to protect the confidentiality of your relationship with us. It is also our policy to inform you of the limits we have in protecting this right to confidential care. Some limitations are imposed by state statute and others come from the ethical standards for therapists or counselors. They are:
a. Ethical standards encourage therapists to confer with other professionals when helpful and appropriate provided you have signed a written release of information form.
b. We are obligated by law to inform relevant parties when there is a clear and imminent danger to an individual to society. We also must report to appropriate authorities when there is evidence of child abuse or abuse of a vulnerable individual.
c. By law, we must comply when records are subpoenaed by proper legal authority.
2. Cost of Services Information . You have the right to be informed of the cost of professional services before receiving the services.
1. You are responsible for supplying accurate and complete information about yourself, your past illnesses, previous counseling, medications, and family/work history, when appropriate.
2. You are responsible for keeping appointments. To avoid charges, CANCELLATIONS MUST BE MADE 24 HOURS IN ADVANCE by calling (601) 346-4479.
3. You are responsible for honoring your financial agreement.

I have read the information on client’s rights and responsibilities and understand and accept these policies.

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