Parental Consent FormPlease enable JavaScript in your browser to complete this form.Name of Parent or Legal Guardian *FirstLastI do hereby give my Parental/Custodial consent for the named below minor to receive Biblical Counseling. *Yes, I give my consent.Name of Minor Counselee *FirstLastI approve that biblical counseling will be offered by *Elaine RussoTim RussoSERVICES AND FEES *I understand the following statement:I will be charged for each 50-minute counseling session. The session fee has been communicated to me. This fee is to be paid at the beginning of each session. You may pay with cash, a personal check, credit or debit card. Phone conversations will be charged at the regular rate in 30 minutes increments. For example, if you are on the phone for over 15 minutes, you will be charged for ½ session rate. 30 minutes or more will be a full session charge. This also applies to in-person visits that take place either before or after a session. Some churches offer assistance with counseling fees. If you need assistance, you can check with your church. We are a private pay service, therefore we do not accept nor submit insurance payments.MISSED APPOINTMENTS AND LATE CANCELLATIONS *I understand the following statement:Clients/counselees are asked to cancel appointments at least 24 hours prior to the appointment. This gives others the opportunity to use the canceled time slot. If no cancellation is made, or if less than 24-hour’s notice is received, except for absolute emergencies, then you will be charged for the appointment, as follows: one-half of your counselor's standard fee per session for the first late cancellation; a full-fee for failure to call and cancel OR for any subsequent late cancellations. If you had a double session scheduled, then the above rates also double. ABOUT CONFIDENTIALITY *I understand the following statement:Usually, anything discussed with your counselor and all information on this intake will be held in strict confidence. However, there are some situations that may have to be reported to appropriate authorities as required by law. This reporting may take place without your permission or knowledge. Reportable situations include, but may not be limited to, indications of bodily harm to self or others, involvement in a felony, suicidal intentions, and reasonable evidence/suspicion of child/elder/dependent abuse or neglect. Your counselor may also be required to disclose information in response to a subpoena issued by a court of law. Your information will not be shared without your written consent except under legal obligation or for professional consultation. There are also times when a counselor/consultant may consult with others on his or her team for advice. There may also be times when information is given to those you approve of in writing, such as an advocate or family member.I understand and agree with the terms of this agreement *YesName *FirstLastEmail *Today's Date *Submit