Grace For All Families - Minor Counseling Form

Counseling Fee Sheet
(Please initial and date each statement.)
The current fee for counseling sessions is $90. The payment is due at the time of service. Grace For All Families counseling practice accepts the following as payment: cash, credit or debit card, or personal checks. Checks should be made payable to Grace For All Families. In the event of a returned check, the client should make every effort to pay for the session as soon as possible.
Signature*

Clear
Date*

MonthDayYear
Date
Checks should be made payable to Grace For All Families. In the event of a returned check, the client should make every effort to pay for the session as soon as possible.
Signature*

Clear
Date*

MonthDayYear
Date
Dr. Ransom has a 24-hour cancellation policy. Please be courteous: if you cannot keep the appointment, let me know so someone else can have it. Failure to cancel or reschedule within 24 hours of your appointment will result in a $20 office charge to be paid before the next visit, unless in case of emergency or otherwise discussed with Dr. Ransom. No-shows result in the forfeiture of services provided by Grace For All Families.
Signature*

Clear
Date*

MonthDayYear
Date

Counseling/Mental Health Background
Has child/teen received counseling before?

YesNo
Is child/teen currently on any medication for anxiety, depression, or addiction medicine, or other?

YesNo

Goals

(Parents: please fill out this section if child is younger than 13. If they are 13 or older, have them fill out this section themselves.)
What goals do you wish to accomplish in counseling?
In order to understand me:
What really hurts me:
I wish I could change:
My greatest regret is:
My greatest fear is:
My greatest joy is:
Additional Comments: