The Beechland Counseling Ministry 4613 Greenwood Road Louisville, KY 40258 Phone (502) 935-1313 AGREEMENT TO COUNSEL (Please provide completed copy to client):
This agreement is made this _________ day of _________________________, ______________, by and between __________________________________________, hereinafter referred to as “Counselor”, and ______________________________________________________________________, whose address is _____________________________________________________, hereinafter referred to as “Counselee”. The parties agree as follows: 1. The Counselor shall provide counseling to individuals or groups as relates to personal or family matters, including religious issues when appropriate. The Counselor shall not offer medical, legal, or psychiatric services, nor shall the Counselor dispense any type of drugs or medications. The Counselee shall seek services of these types elsewhere as needed. 2. The Counselor shall provide counseling services to the Counselee on a per session basis. 3. The Counselee shall pay to the Counselor $___________ per counseling session. Electronic or telephone contacts other than those related to appointment scheduling may be subject to the same fees as the on-site session. Additionally Beechland does not guarantee the security of ecommunications including, but not limited to texting. 4. In the event the Counselee fails to attend or cancels any scheduled session less than twenty-four hours in advance, the Counselee shall pay to the Counselor an amount equal to the counseling session rate. The Counselee that has fees waived or reduced based on financial need may be subject to a minimal charge ($20.00) for failure to attend or cancellation less than twenty-four hours in advance. 5. After the third incident of failure to attend without twenty-four hours prior notification, the Counselor reserves the right to terminate the counseling relationship. Additionally, Beechland Counseling Ministry reserves the right to refuse to offer treatment from other staff counselors. 6. The Counselee gives the Counselor permission to reproduce sessions in writing, or through the use of audio/video recording devices, for use in consultation with supervisor/director of BCM or in supervision with the supervisor/director. 7. All counseling sessions between Counselor and Counselee shall remain confidential, unless expressly agreed upon in writing. Confidentiality is limited as defined by law which includes, but is not limited to, incidents of abuse, violence, suicide attempts, unsafe behavior, etc. 8. The Counselee shall not subpoena the Counselor or his /her notes as part of any legal action. 9. If necessary, the Counselor shall refer the Counselee to other counselors, physicians, governmental or private agencies deemed by the Counselor to be in the best interest of the Counselee.
Form 03 - AGREEMENT TO COUNSEL, DISCLOSURE STATEMENT and INFORMED CONSENT
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