thread & tether | quiet intake form

thread & tether | quiet intake form
this practice is held in quiet. if you’ve found your way here, the rhythm is already known. please complete the form below to begin. once received, you’ll be contacted privately to arrange your first session.
where are you based.*

united statesunited kingdom
are you seeking individual or couples therapy.

individualcouples
full legal name.

first namelast name
email address.
example@example.com
phone number. please include your country code (e.g., +1, +44).*
date of birth.

MonthDayYear
date
partner’s full legal name.

first namelast name
partner’s email address.
example@example.com
partner's phone number. please include your country code (e.g., +1, +44).
partner’s date of birth.

MonthDayYear
date
nature of therapy.

therapy is a quiet collaboration. at times it may feel uncertain, vulnerable, or even disorienting. you understand that therapy does not promise outcomes, and that meaningful change unfolds gradually, through mutual effort.
voluntary participation.

you are here by choice. you may pause, redirect, or end our work at any time. you may decline any approach, ask questions about the process, or reflect aloud about our work. there is no obligation to continue beyond what is useful and right.
confidentiality.

our sessions are held in confidence. that trust is protected, with rare exceptions:
– if there is imminent risk of serious harm
– if there is suspected abuse of a child, elder, or dependent adult
– if compelled by a court order or subpoena
– if you provide written permission
– or if discussed anonymously during clinical consultation
record keeping.

minimal records are maintained, securely and privately. these are not shared with anyone unless required by law or you provide explicit written consent. this practice is intentionally lean, built to reduce digital exposure and preserve discretion.
contact between sessions.

communication outside of sessions is brief, logistical, and quiet. therapeutic content will be reserved for our time together. extended contact may require a session. this is not a crisis practice. in an emergency, call 911 (or 999 in the uk) or visit the nearest er.
session format (telehealth).

if meeting virtually, you agree to join from a private location with a stable connection. no third parties, recordings, or shared spaces. i may pause or end a session if conditions are not clinically appropriate.
cancellations & termination.

sessions cancelled with less than 48 hours’ notice are billed in full. if we do not meet or communicate for three weeks, therapy is considered formally concluded unless pre-arranged.
public presence & reviews.

this practice is not listed publicly and maintains no social media. you agree not to leave public reviews or testimonials to preserve the privacy and integrity of the work.
fees & payment.

this is a private-pay practice. no insurance is accepted or billed. payment is collected at the time of scheduling via a secure link. superbills are available by request but may not be reimbursed by your provider. for clients based in the united kingdom, fees are collected in gbp; for those based in the united states, in usd.
acknowledgment.*

i understand this is a private-pay practice and no insurance is accepted.i have read and consent to the practice policies and conditions listed above.i understand the 48-hour cancellation policy and 3-week termination clause.i consent to begin therapy with Jason Powell, LMFT, CST.
signature.

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full legal name (typed).

first namelast name
date signed.

MonthDayYear
date
partner's signature.

Powered by Jotform SignClear
partner's full legal name (typed).

first namelast name
date signed (partner).

MonthDayYear
date
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