The information requested on this form will be kept confidential. Please fill out the form as completely as possible.
The information written on this form is accurate, to the best of my knowledge.
New Hope Counseling Center utilizes a contracted text service to provide automated reminders of your next appointment 24 – 48 hours in advance as a courtesy reminder.
When you schedule an appointment with our staff, New Hope Counseling Center reserves that time just for you. If you are not going to attend your scheduled appointment, we would like to give another client the opportunity to take that opening. It affects our funding, our ability to budget our staff, and staff salaries when there are missed appointments. That is why we require 24-hour advance notification of cancellation. Leaving a message on our voicemail is fine, even on weekends. The time you called will be posted with the message. If you fail to give 24-hour notice before cancelling your appointment or do not show for your appointment up to two times, your therapist has the right to refuse services or you may be asked to make your appointment two to three weeks from missed appointment date. We appreciate the courtesy you extend to us by honoring this agreement. Please note that we cannot bill your insurance company for missed sessions or for late cancellations.
Weather Related: Missed appointments due to dangerous weather will not count as a late cancellation.
Due to the counselors maintaining a set schedule:
By signing this agreement I acknowledge my understanding of all the policies listed above. I accept and agree to all of the above terms during the course of my treatment at New Hope Counseling Center.
I have been provided with a printed copy of the Explanation of Psychotherapy/Counseling Services and Notice of Privacy Practices packet. In addition, the therapist/counselor/clinical social worker has provided a verbal explanation of psychotherapy/counseling/clinical social work services and privacy practices, to include exceptions to confidentiality. I have been afforded an opportunity to review the Explanation of Psychotherapy/Counseling Services and Notice of Privacy Practices packet, other pertinent information, and to ask questions. All questions have been answered to my satisfaction.
I am making an informed decision, free of any coercion, to engage in psychotherapeutic/counseling/clinical social work services. It is my right to terminate these services at any point.