Adult Consent Form
I understand that the staff of Tampa Family Resources, Inc. and those associated with them are not licensed mental health counselors, therapists, medical or psychological practitioners. I understand that Tampa Family Resources, Inc. counseling staff offers counseling with a biblical value base. The counselors are board certified with the International Board of Christian Care and with the American Association of Christian Counselors.
I understand that my participation in the counseling process is voluntary and I am free to discontinue attendance at any time. I understand that there is a $90.00 charge for the 1 ½ hr. intake session. I also understand that for second and subsequent sessions, there will be a $60.00 charge per hourly session to help support Tampa Family Resources, Inc. Since Tampa Family Resources, Inc. is a 501c3 the charge can be counted as a charitable donation by the client. Accepted methods of payment are check, cash, or major credit cards (Visa, MasterCard, American Express, and Discover Payment is expected at the time services are rendered. There will be a $25.00 cancellation fee for any appointment that is cancelled within 24 hours of session.
I understand that after the initial intake session, my counselor will commit to several weeks of brief therapy format to address the issues for which I have sought counseling. After the format has concluded, a re-evaluation will be made concerning future counseling sessions. I understand that the information I disclose in counseling is confidential. Confidentiality is assured unless there is reason to suspect that a child under the age of 18 or an adult over the age 65 is endangered by abuse or I am a danger to myself or others. I understand that I may ask for clarification of any part of this statement.