INTAKE FORM

Empowerment Counseling Group

About our Services
The potential benefits of counseling are many and include improved personal functioning, relationships,
self-image, mood, and the attainment of personal goals. However, in some cases persons have reported
feeling worse after counseling. Clients understand that healing and growth is difficult, and some
discomfort will likely be a part of the counseling process.

Confidentiality / Personal Health Information
All communications and records with your counselor are held in strict confidence. Information may be
released, in accordance with state law, when (1) the client signs a written release indicating consent to
release; (2) the client expresses serious intent to harm self or someone else; (3) there is reasonable
suspicion of abuse against a minor, elderly person, or dependent adult; (4) to acquire payment for
services or for billing purposes, or (5) a subpoena or court order is received directing the disclosure of
information. To protect your privacy to the greatest extent of the law, it is our policy to assert either (a)
privileged communication in the event of #5 or (b) the right to consult with clients, if at all possible,
before mandated disclosure in the event of #2 or #3.


Electronic Communication. Electronic communications, both telephone and Internet (including email),
are not secure methods of communication, and there is some risk that one’s confidentiality could be
compromised with their use. Counselors at Empowerment Counseling Group, sometimes communicate
with clients using these mediums. If you would prefer to not be contacted by telephone or email, please
inform your counselor and we will honor this request.


Client Follow Up. Your counselor may “follow up” with you after counseling /life coaching has ended. 1
month, 3 month, or 6 month follow up calls may be made to check in with clients and see if gains made
in counseling have been maintained. In addition, someone from our team might call you to ask for your
feedback on your experience at Empowerment Counseling. If you would prefer that Empowerment
Counseling Group not contact you, simply inform your counselor and your preferences will be respected.

Scheduling and Cancellations
Scheduling an appointment is a commitment that both counselors and clients honor. Appointments can
be cancelled or rescheduled if a 72-hour notice is provided. If sessions are cancelled or rescheduled with
less than the required notice, or if a client misses a session, the client agrees to pay for that session
(insurance will not pay for missed appointments). Please know that exceptions to this policy may be
made in the instance of a serious medical emergency, or serious family emergency.

Work Agreement
It is agreed that the client shall engage in the counseling process as an important priority in his or her
life. Suspension, termination, or referral shall be discussed between counselor and client for a pattern of
behavior showing disinterest, lack of commitment, or for any unresolved conflict or impasse between
counselor and client.

Conflict Resolution

We work hard to make sure that you have a positive counseling experience.
However, if a conflict occurs, it is agreed that any disputes shall be negotiated directly between the
parties. If these negotiations are not satisfactory, then the parties agree to mediate any differences with
a mutually acceptable third-party mediator. If these are unsatisfactory, then the parties shall move to
arbitration, and then binding arbitration, choosing an arbitrator mutually agreeable to both. Litigation
shall be considered only if and after all these methods of resolution are given a good faith effort and are
unsatisfactory.

Emergency Contacts
Your counselor will establish emergency contacts for you, such as the phone number and location of a
family member. Your counselor will also obtain alternative methods for contacting you, such as a mobile
phone, or work phone number. These emergency contacts may be used if the counselor perceives a
need. If you are in crisis and cannot reach your counselor, please contact emergency services (911) or go
to your nearest emergency room.

Service Fees
Payment is due at the time of your scheduled session. Any insurance co-pays or deductibles are due at
the time of the session. Unfortunately, we cannot extend credit or provide services until payment is
made. Clients understand they are fully responsible for all fees if insurance or other vendor does not pay
for any reason.