COUNSELING INTAKE FORM

INITIAL COUNSELING INTAKE FORM
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Age
Email
Cell Phone
In order to provide exceptional follow-up care for you as a client, AWC Centers would like permission to contact you by a variety of methods.
Permission to contact by:

EmailPhoneTextVoicemail
EMERGENCYCONTACT:
Name

First NameLast Name
Relationship
Phone
Do you live in Bexar County?*

YesNo
If no, which county do you live in?

AtascosaBanderaComalKendallMedinaWilsonOther
CASE INFORMATION
Why are you currently seeking counseling?
Are you a former AWC medical client?

YesNo
Date Seen:

MonthDayYear
Date
Are you the parent, spouse, or partner of an AWC client?

YesNo
Client name:

First NameLast Name
Are you a female between the ages of 13 to 99 with a history of unplanned pregnancy, sexual health issues, sexual assault, child abuse or neglect, self-esteem and relationship problems, or anxiety, depression, or emotional instability that may affect your sexual health?

YesNo
DEMOGRAPHIC INFORMATION
Race/Ethnicity (check one):

African AmericanAsianCaucasian / HispanicCaucasian / Non-HispanicAmerican Indian or Alaskan NativeNative Hawaiian or Pacific IslanderBiracial or MultiracialUnknown
Current Martial Status (check one):

SingleEngagedMarriedSeperatedDivorcedWidowed
Name of Significant Other:

First NameLast Name
Children's Names/Ages:
Education (highest level completed):

Middle SchoolHigh SchoolAssociatesUndergraduateGraduateOther
Current Student Status (check one):

Middle SchoolHigh SchoolAssociatesUndergraduateGraduateNot a student
How did you hear about AWC Centers? (check all that apply)

Internet searchHealth fairNonprofit agencyBrochureSocial mediaSocial servicesCraigslistStreet bannerPregnancy centerDrive byWord of mouthSchool/collegeClinicDoctorOther
MENTAL HEALTH HISTORY
Have you ever received counseling or psychotherapy?

YesNo
Provider:
Have you been diagnosed with a mental health disorder?

YesNo
Diagnosis:
Have you ever attempted suicide or physical self-harm?

YesNo
Date(s):
Have you ever been hospitalized for emotional difficulties?

YesNo
Date(s):
Have you ever been prescribed psychiatric medication?

YesNo
Medication(s):
Are you currently taking any psychiatric medication?

YesNo
Medication(s):
Do you have any other significant medical issues?

YesNo
Describe:
Are you currently in any counseling or recovery group?

YesNo
What/Where:
FINDING YOUR ACE SCORE

Prior to your 18^th birthday:

1.    Did a parent or other adult in the household often or very often…
Swear at you, put you down, or humiliate you?
OR
Act in a way that made you afraid that you might be physically hurt?
Yes     No                                                       If yes, enter 1

2.    Did a parent or other adult in the household often or very often…
Push, grab, slap, or throw something at you?
OR
Ever hit you so hard that you had marks or were injured?
Yes   No                                                        If yes, enter 1

3.    Did an adult or person at least 5 years older than you ever…
Touch or fondle you or have you touch their body in a sexual way?
OR
Attempt or actually have oral, anal, or vaginal intercourse with you?
Yes   No                                                        If yes, enter 1

4.    Did you often or very often feel that…
No none in your family loved you or thought you were important or special?
OR
Your family didn’t look out for each other, feel close to each other, or support each other?
Yes   No                                                        If yes, enter 1

5.    Did you often or very often feel that…
You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?
OR
Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Yes   No                           If yes, enter 1

6.    Were your parents ever separated or divorced?
Yes   No                                                       If yes, enter 1

7.    Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had something thrown at her?
OR
Sometimes, often, very often kicked, bitten, hit with a fist, or hit with something hard?
OR
Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
Yes   No                                                         If yes, enter 1

8.    Did you live with anyone who was a problem drinker or alcoholic or who usd street drugs?Yes   No                                                          If yes, enter 1

9.    Was a household member depressed or mentally ill or did a household member attempt suicide?
Yes   No                                                            If yes, enter 1

10.  Did a household member go to prison?
Yes No                                                         If yes, enter 1

Now add up all your “Yes” answers:     This is your ACE Score
PERSONAL HISTORY
Do you use drugs?

YesNo
Describe:
Do you drink alcohol?

YesNo
Describe:
Do you smoke cigarettes?

YesNo
Describe:
Do you smoke marijuana?

YesNo
Describe:
Do you have sleep problems?

YesNo
Describe:
Do you exercise regularly?

YesNo
Describe:
Do you have a balanced diet?

YesNo
Describe:
What medications have you taken in the last 24 hours?
What drugs or alcohol have you taken in the last 24 hours?
Were you abused or neglected as a child?

EmotionalPhysicalSexualNeglectNo abuse
Age(s):
Were you abused or neglected as a child?

EmotionalPhysicalSexualOtherNo trama
Age(s):
What kind of stress do you have in your life?

RelationalFinancialMedicalDivorceDeathMoveJob
What is your current state of physical health?

ExcellentGoodAveragePoorVery Poor
What is your state of emotional health?

ExcellentGoodAveragePoorVery poor
How satisfied are you in your personal life?

CompletelyPartiallyNot at allNeither satisfied nor dissatisfied
How satisfied are you in your professional life?

CompletelyPartiallyNot at allNeither satisfied nor dissatisfied
Do you have any spritual beliefs?

YesNo
Were you raised in a religious family?

YesNo
What are your current religous beliefs?

AtheistAgnosticBuddhistCatholicChristianHinduJehovash's WitnessJewishMormonMuslimWiccanNoneOther
Do you attend a place of worship?

YesNo
If yes, where?
Have any of your immediate family members had past, present, or impending issues with any of the following? (check all that apply):

Alcohol/drug abuseAnxiety disordersBipolar disorderCompulsive disordersDepressionEating DisordersFamily ViolenceFinancial problemsLegal problemsPhysical/Sexual abuseSchizophreniaSerious illnessSuicide or self-harmUnemploymentOther
What is your parent's maritial status?

MarriedDivorceSeperatedDad remarriedMom remarriedNever were married
Is your father deceased?

YesNo
Year deceased?
If living, are you still in contact?

YesNo
Is your mother deceased?

YesNo
Year deceased?
If living, are you still in contact?

YesNo
In general, how happy or well-adjusted were you growing up?

Completely happyPartially happyNot happyUnsure
How much is your family source of emotional support for you?

Substantial supportSome supportNo supportUnsure
How much conflict in values do you have with your parents?

Substantial supportSome supportNo supportUnsure
Who in your family are you the closest to?
Who do you feel the most distant from?
Who are you in conflict with the most?
CHECKLIST OF CONCERNS

AbortionAbuse - emotionalAbuse - neglectAbuse - physicalAbuse - sexualAdoptionAlcohol useAnger/agressionAnxietyAttention problemsBullying - pastBulling - presentChildhood issuesChild custodyChronic painCodependenceCommunicationConfusionCompulsivenessDeath/mourningDecision-makingDelusionsDepressionDivorce/seperationDomestic violenceDrug use - alcoholDrug use - nonprescriptionDrug use - prescriptionDrug use - street drugsEating disorderEmployment issuesEmptinessFailureFears/phobiasGamblingGriefGuilt/sameHallucinationsHealth issuesHearing voicesImpulsivenessIndecisionInfertilityInterpersonal conflictIrritabilityJudgment problemsLegal issuesLonelinessLoss of controlLoss of interestMarital conflictMemory problemsMenopauseMenstrual/PMSMoney problemMood swingsNervousnessNightmaresObsessionsOutburstOversensitivityOverspendingPanic attacksParenting issuesPerfectionismPessimismPoor self- carePornographyProcrastinationRelationship issuesRisk-takingSadnessSchool problemsSelf esteemSelf harmSexual - addictionSexual - assaultSexual - confusionSexual - otherShynessSleep disturbancesSmoking/tobaccoSpiritualityStressSuicidal thoughtsSuspiciousnessThought disorganizationTiredness/lack of energyViolenceWeight gain or lossWithdrawalWorry/distress
QUESTIONNAIRE
What are 3 goals you want to achieve in counseling?
SELF EVALUATION

Rate yourself on the following:
Communication... giving and recieving information

Very PoorPoorAverageGoodVery good
Coping skills... effectively dealing with hardships

Very PoorPoorAverageGoodVery good
Decision-making... making good life choices

Very PoorPoorAverageGoodVery good
Emotional stability... making consistent moods

Very PoorPoorAverageGoodVery good
Goal setting... planning and achieving your dreams

Very PoorPoorAverageGoodVery good
Goal setting... planning and achieving your dreams

Very PoorPoorAverageGoodVery good
Relationships... developing healthy connections

Very PoorPoorAverageGoodVery good
Self-control... managing thoughts and behaviors

Very PoorPoorAverageGoodVery good
Self-esteem... believing in your own value and worth

Very PoorPoorAverageGoodVery good
Sexual health... avoiding physical and emotional risk

Very PoorPoorAverageGoodVery good
COUNSELING INFORMED CONSENT
Client Name:
CONSENT & CONFIDENTIALITY
I acknowledge that I have read, understand, and agree with AWC Centers, LLC’s Counseling Informed Consent. I hereby consent for AWC to evaluate, treat, and/or refer me to other providers for services as needed. AWC is a teaching facility and many of the counselors are students or interns. I understand that my counselor may be a master’s level counseling graduate student, Licensed Professional Counseling Intern, or Licensed Marriage & Family Associate in the state of Texas. All interns and students are supervised by a licensed supervisor and they are required to have regular meetings where cases may be discussed. I agree to waive confidentiality relating to case discussions between my counselor and their clinical supervisor to ensure that I receive the best possible counseling experience.
Signature of Client or Representative*

Clear
Date

MonthDayYear
Date
AWC Centers
AWC Centers

Welcome to AWC Centers (AWC). This informed consent will provide you with information regarding our business practices and available counseling services. Please read over this document carefully. The informed consent is subject to change but you will receive written notification of any changes and will have the opportunity to approve them. You may also request a copy for your records.

APPOINTMENTS

All counseling sessions begin and end on time and last 50 minutes. On the rare occasion that your counselor is running late or in an emergency situation, someone will inform you of the approximate wait time and reschedule if necessary. Please do not be late to your appointment. If you are more than 10 minutes late, you will be rescheduled. AWC also has a 24 hour cancellation policy. This means that you are required to cancel your appointment at least 24 hours in advance. Monday appointments should be canceled by 2 pm the Friday before. Please be considerate of this as our sessions are limited and other clients may be waiting for an appointment.

CHILDCARE

Please do not bring children or babies to counseling unless you have a family session scheduled. Children are disruptive to counseling sessions and they cannot remain in the waiting room. Making childcare arrangements prior to your appointment will ensure that you receive high-quality services and will also protect our pregnant clients and their unborn babies from common childhood diseases.

COUNSELING SERVICES

AWC services include individual, couples, family, and marriage counseling for our medical clients, members of their immediate support systems, and all females with self-esteem, relationship, or sexual health issues. Your counselor will determine during the initial session if you qualify for counseling services at AWC and how to best meet your needs. Referrals will be made if you don’t qualify for AWC Center’s professional counseling program or if the counselor believes you’ll be better served by another provider.

CUSTODY OF FILES

CUSTODY OF FILES Electronic counseling records are kept by AWC. All records are kept for the period required by The Texas Behavioral Health Executive Council Board of Examiners (TBHECBE) for the counselor’s specific licensure. Most records are kept a minimum of five (5) years. Security and privacy are also governed by TBHECBE.

FEES & PAYMENT

AWC is a nonprofit health center funded solely by donations from the community. All counseling services are free-of-charge to clients.

COURT ORDERED COUNSELING, PROBATION REQUIREMENTS, CUSTODY EVALUATIONS, AND OPEN LEGAL CASES

AWC counselors do not perform forensic mental health services related to child custody, divorce, or other legal proceedings or for disability or unemployment claims. AWC cannot provide “forensic opinions, reports, assessments, and/or recommendations” according to Rule 465.18 of the Texas Administrative Code. Due to the experience level of our volunteer counselors, we cannot offer counseling services to those on probation or those engaged in open or active legal cases.

MARRIAGE & FAMILIES

Marriage counseling involves meeting with the counselor both individually and as a couple. As the relationship becomes more harmonious, fewer individual sessions will be scheduled unless you need individual counseling for issues unrelated to your marriage. Information obtained during individual sessions will remain confidential from the spouse, but every effort will be made to encourage you both to confide in each other. If an individual reveals that he or she is engaging in an extramarital affair without the spouse’s knowledge, he or she will be asked to end the affair and work with the counselor toward providing full disclosure to the spouse.

Family counseling is typically done by a Marriage and Family Therapy student or intern. During family counseling, the entire family may be seen but appointments can be divided into individual sessions and end with a group session based on the family’s needs. Please read the section on “Treatment of Minors” for more information about counseling individuals under the age of 18.

COUNSELING INFORMED CONSENT

PHONE CONTACT

Counselors are not usually available to take calls but you can leave a message and they will call you back at the end of the day or during their next shift. They have permission to contact you by any method you approve on the case opening form. If you need immediate assistance, contact your psychiatrist or primary care doctor. In the event of an emergency, call 911 or go to the nearest emergency room.

PRIVACY PRACTICES

Texas law and the Health Insurance Portability & Accountability Act of 1996 (HIPAA) require that AWC protect your health information. Effective counseling may require the sharing of confidential information at times with AWC employees, counseling students and interns at the center, and their supervisors. AWC shares information for both clinical and administrative purposes. Center personnel abide by the rules of confidentiality and maintain strict privacy standards. See the attached Notice of Privacy Practices for more information.

PROFESSIONALISM

The counseling relationship is strictly a professional one. Contact with your counselor is usually limited to scheduled sessions. Counselors at AWC do not correspond via email or text since this communication is often not secure. You will benefit greatly when the counseling relationship remains professional and the sessions concentrate exclusively on your concerns.

RECORDS REQUESTS

Counselors maintain confidentiality according to the ethical guidelines of their licensure and legal requirements. While you are entitled to a copy of your record, we do not recommend this due to the possibility of misinterpreting notes which are written for the healthcare professional and are often abbreviated with medical shorthand. A verbal summary can be provided upon request or a written narrative.

STATEMENT OF ETHICS

Licensed Professional Counselors (LPCs) are regulated by the Texas State Board of Examiners of Professional Counselors and Licensed Marriage & Family Therapists (LMFTs) are regulated by the Texas Board of Examiners of Marriage and Family Therapists. These boards carry out general oversight of licensed counselors in the state of Texas. Licensed counseling professionals provide services in accordance with state law and board regulations. This includes following a code of ethics established for the counseling profession. You should expect to be treated with dignity and in a professional manner at all times. If you have a concern, please speak to your counselor or to AWC’s counseling site supervisor. If you’re unable to resolve the problem, you may file a consumer complaint by calling the state’s toll-free complaint hotline at 1-800-942-5540. Written complaints may be mailed to: Complaints Management & Investigative Section, P.O. Box 141369, Austin, TX 78714-1369. Visit dshs.state.tx.us/counselor for more information or to view counselor licensure status.

STATEMENT OF FAITH

AWC is a faith-based ministry and our counselors practice from a Christian worldview. However, professional counseling must be a client-centered experience. There are no religious requirements and any discussion of faith or religion is guided by you, the client.

TERMINATION OF SERVICES

You may choose to discontinue the counseling relationship at any time and your counselor will be supportive of that decision. The goal of professional counseling is for you to be successful facing life’s challenges without the support of a counselor. If you decide to terminate services, please notify your counselor and complete an exit survey to help us evaluate the effectiveness of our program.

TREATMENT OF MINORS

If a child is under the age of 18, he or she will only be treated with the consent of a parent or legal guardian. In situations of divorce, the parent with legal custody must sign the documents authorizing professional counseling. The non-custodial parent may bring the child to counseling appointments, but only after the custodial parent has given permission and signed the informed consent. Please understand that in order to maintain trust with your child, the counselor will not discuss confidential conversations that take place in counseling sessions. If a child does not feel safe to confide in his or her counselor, the treatment process can be greatly hindered.

Parents usually have the right to see their child’s record, but AWC discourages this and would prefer to provide a summary upon request. If your child’s counselor believes it would endanger your child in any way to reveal their record, the counselor will seek the advisement of their clinical supervisor or the Texas State Board of Licensure prior to releasing the record. In cases involving suicide prevention, chemical substance abuse or dependence, or physical, emotional, or sexual abuse, the record will not be released to the parents.

WHAT TO EXPECT NEXT

After signing the informed consent, you will meet with your counselor for an initial session. The counselor will assess your needs and determine if you qualify for our program. The counselor will also decide if they have the skills and experience to help you or if you’d be better served by a referral. This is the time for you to decide if this is the right therapist for you. The decision to continue counseling requires a time commitment so you should be comfortable with your choice. This marks the beginning of the therapeutic relationship.

Once the counseling relationship has been established, your counselor will meet with you regularly for 50 minute sessions. Sessions can be weekly or more or less frequent based on your individualized treatment plan. It’s important to work with your therapist, giving honest feedback if you feel uncomfortable with a suggested technique or approach. Counseling is an interactive process that requires work both in session and at home. You must complete the work that you and your counselor agree upon to receive the full counseling experience.

There are benefits and risks associated with professional counseling. Counseling can improve relationships and self-image and help you to understand yourself, your values, and your goals. Counseling may also result in unexpected feelings that can impact you and your relationships. Your counselor at AWC Centers will work with you to create a positive therapeutic experience.
COUNSELING POLICY ACKNOWLEDGMENTS
NOTICE OF PRIVACY PRACTICES

I acknowledge that I have read and received a copy of AWC Centers, LLC’s Notice of Privacy Practices. This Notice describes how AWC Centers disclose my protected health information, restrictions on the use and disclosure of my protected health information, and the rights I have regarding my health records. This Notice of Privacy Practices goes into effect as of January 1, 2016.
Name of Client
Signature of Client or Representative*

Clear
Date of Birth

MonthDayYear
Date
Date of Receipt

MonthDayYear
Date
CONSENT FOR COUNSELING SERVICES FOR A MINOR
I acknowledge that I am the natural custodial parent or legal guardian of the minor child named below and I hereby authorize AWC Centers to evaluate, treat, and/or refer this minor child for psychological services. I understand that it is mandatory for a parent or legal guardian to grant permission for individuals under the age of 18 to receive counseling services. In cases of divorce, the legal custodial parent of the minor child must provide consent, but both natural parents may have the right to obtain information regarding the nature and course of treatment for their child. If I’m a divorced parent, stepparent, grandparent, etc., I agree to provide a copy of the court order naming me the legal custodian of this minor child. I understand that services will not be provided without proof of legal guardianship.
Name of Minor Child
Date of Birth

MonthDayYear
Date
Name of Parent or Legal Guardian
Relationship
Signature of Parent or Legal Guardian

Clear
Date of Consent

MonthDayYear
Date
COUNSELING POLICIES & PROCEDURES
CANCELLATIONS

Appointments must be canceled at least 24 hours in advance (by 5 pm Fri. for Mon. sessions). You will not be able to return until 30 days have lapsed after 2 appointment cancellations or 1 no show. Cases are also closed after 2 months of no contact. In this situation, you may be eligible to return but will need to resubmit paperwork. *  (initial)

CHILDCARE

Common childhood diseases can be dangerous for expectant mothers and their unborn children. For everyone’s safety, please make childcare arrangements for children over the age of 6 months prior to your visit. If you have any questions or concerns about our childcare policy, please feel free to ask at the front desk. *   (initial)

COURT   ORDERED COUNSELING, PROBATION REQUIREMENTS, CUSTODY EVALUATIONS, AND OPEN LEGAL CASES

AWC counselors do not perform forensic mental health services related to child custody, divorce, or other legal proceedings or for disability or unemployment claims. AWC cannot provide “forensic opinions, reports, assessments, and/or recommendations” according to Rule 465.18 of the Texas Administrative Code. Due to the experience level of our volunteer counselors, we cannot offer counseling services to those on probation or those engaged in open or active legal cases. *   (initial)

RECORDINGS

Due to the confidential nature of our services and to protect the privacy of our clients, this center and its staff do not consent to being recorded. Please turn off all electronic devices with audio and/or video recording capabilities while you’re at AWC and do not record others, even in the front waiting area. *   (initial)

REFERRALS

AWC refers to other providers when counseling clients don’t qualify for the program or are unstable, in need of specialized therapeutic services (ex. psychiatric, addiction), or potentially pose a threat to themselves or others. Counseling referrals are made on a case-by-case basis at the discretion of the site supervisor. *   (initial)

SCOPE OF SERVICES

There are no minimum or maximum number of counseling sessions required at AWC since each client’s situation is different. However, all new counseling clients should be aware that therapeutic progress often takes time and to plan for at least 4 to 5 counseling sessions. Cases are reevaluated on an ongoing basis. *   (initial)

*
COUNSELING LPC-INTERN/ STUDENT AGREEMENT
AWC Counseling Intern Agreement describes the therapeutic relationship between a counseling client and their student or intern counselor. The client and counselor will review and sign the agreement together during the initial intake session.
AGREEMENT STATEMENTS:
I understand that I am seeing a counseling master’s level student or LPC intern for counseling services and that this student/intern is earning hours toward professional counseling licensure.

I understand that my counselor has a clinical supervisor with whom my counselor may discuss my case for staffing and educational purposes.

I understand that to best serve my needs and therapeutic progress, some of my counseling sessions may be discussed by self-report with my counselor’s clinical supervisor.

I understand that the supervisory relationship and requirements for supervision do not otherwise affect my right to confidentiality, which will be maintained within the limits of the law.

I understand that I may request to contact my counselor’s clinical supervisor to discuss any concerns about my counselor intern and that their name and phone number are listed below.

I understand the limits of confidentiality per AWC’s Notice of Privacy Practices and as explained by my counselor. I’ve had the opportunity to ask questions about these limits.

I understand that I am not required to sign this document. If I choose not to sign it, I will be provided with referrals to other providers for counseling services.

COUNSELORS & SUPERVISORS:
Signature of Client or Representative*

Clear
Date

MonthDayYear
Date
Relationship to Client
AWC Telecounseling Consent

1. During this pandemic, the Pregnancy Center is using telehealth/teleconferencing platforms to assist our clients/patients. The Center is utilizing the most secure platforms possible as permitted by current regulations. Please be advised, however, that there are potential benefits and risks of providing telehealth/teleconferencing services (e.g. limits to confidentiality) that differ from in-person sessions.   By signing below you acknowledge that there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties.

2. The Center may only provide telehealth services in-state. The Center is located at 14855 Blanco Road, San Antonio, TX 78217; telephone number (210)370-3939. By signing below, you represent that you are physically located in the State of .  Your address and telephone number are:   .

3. No recordings are permitted. Confidentiality applies for telehealth/teleconferencing services, and participants are NOT permitted to record the sessions without the permission from the other participant(s).

4. In order to preserve confidentiality, it is important to be in a quiet, private space that is free of distractions during the session. It is also important to use a secure internet connection rather than public/free Wi-Fi.

5. The Center believes that the delivery of services via telehealth/teleconferencing is consistent with the standard of care for an in-person visit, and is appropriate. Either participant may discontinue the consult/visit if it is felt that the conferencing connections are not adequate for the situation. In-person services may be scheduled as appropriate.

By signing this form, I certify:

·      That I have read or had this form read and/or had this form explained to me.
·      That I fully understand its contents including the risks and benefits.
·      That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
·      I hereby authorize the use of telehealth/teleconferencing in the course of the services I receive from the Center.
Patient's name & signature*

Clear
Date

MonthDayYear
Date
Please upload a photo of your ID:

Browse Files

Cancelof
Should be Empty:

INITIAL COUNSELING INTAKE FORM

EMERGENCYCONTACT:

CASE INFORMATION

DEMOGRAPHIC INFORMATION

MENTAL HEALTH HISTORY

PERSONAL HISTORY

QUESTIONNAIRE

SELF EVALUATION

COUNSELING INFORMED CONSENT

CONSENT & CONFIDENTIALITY

AWC Centers

COUNSELING POLICY ACKNOWLEDGMENTS

CONSENT FOR COUNSELING SERVICES FOR A MINOR

COUNSELING POLICIES & PROCEDURES

COUNSELING LPC-INTERN/ STUDENT AGREEMENT

AGREEMENT STATEMENTS: