Registration and Release Couples

REGISTRATION AND RELEASE FORM - COUPLES
CONTACT INFORMATION - PARTNER A
Partner A Name*

First NameMiddle NameLast Name
Partner A Date of Birth*

MonthDayYear
Date
Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
May we leave a message?

YesNo
Cell Phone*
Please enter a valid phone number.
May we leave a message?*

YesNo
May we text you?*

YesNo
Work Phone
Please enter a valid phone number.
May we leave a message?

YesNo
Email Address*
example@example.com
May we email you?*

YesNo
Emergency Contact Name*
Emergency Contact Phone *
Please enter a valid phone number.
Relation to Emergency Contact*
Race
Religion / Spirituality - describe any connection
Gender*
Pronouns
Sexuality
Learning / Physical Ability Challenges
Additional personal / cultural identifiers you would like me to know
CONTACT INFORMATION - PARTNER B
Partner B Name*

First NameMiddle NameLast Name
Partner B Date of Birth*

MonthDayYear
Date
Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
May we leave a message?

YesNo
Cell Phone*
Please enter a valid phone number.
May we leave a message?*

YesNo
May we text you?*

YesNo
Work Phone
Please enter a valid phone number.
May we leave a message?

YesNo
Email Address*
example@example.com
May we email you?*

YesNo
Emergency Contact Name*
Emergency Contact Phone*
Please enter a valid phone number.
Relation to Emergency Contact*
Race
Religion / Spirituality - describe any connection
Gender*
Pronouns
Sexuality
Learning / Physical Ability Challenges
Additional personal / cultural identifiers you would like me to know
Relationship Details
How long have you been in your relationship?*
Do you have children? If YES, please list their names and ages and if they live at home with you.*
What desires, goals, concerns or challenges led you to seek couples counseling?*
Approaches to Healing and Modalities
MODALITIES

David deBardelaben-Phillips is a Certified Imago Facilitator, Certified Exceptional Relationship Mentor, Advanced Certified Core Energetics Practitioner and Reiki Master. In addition, David has completed Level 1 training in the Gottman Method.

Imago Relationships is a structured approach to couples work that explores how early life experiences shape perceptions, behaviors, and patterns in adult relationships. It emphasizes conscious, empathic communication to foster deeper understanding, connection, and relational safety.

Core Energetics is a body-centered approach to mind–body healing that supports increased self-awareness, authenticity, grounding, personal empowerment, and emotional expression. The work may include physical and experiential practices designed to help clients access their life-force energy, deepen emotional awareness, and release areas of held or blocked energy in the body, supporting a more embodied and open-hearted way of living. Exceptional Relationships is a couples model developed as an extension of Core Energetics.

Reiki is a gentle, holistic energy-based practice focused on grounding and supporting balance within the body’s energy system. It is used to promote relaxation, reduce stress, and support overall well-being.

COLLABORATION AND CO-FACILITATION

Some couples work may be facilitated collaboratively by in partnership with Bentley deBardelaben‑Phillips and/or Clare Carr. Collaboration is used intentionally to support depth, safety, and relational attunement within the work. If collaboration is chosen the couple will agree to this before the first session.

Bentley is a certified Exceptional Relationship Mentor and has a background in pastoral counseling. Clare is an Advanced Certfied Core Energetics Practioner, Helix Minsister and has completed training in Imago Relationships.
Financial Agreement & Office Policies

You must acknowledge that you have read, understand, and agree to the Financial Agreement and Office Policies at the bottom of this section.
WELCOME!

We are committed to providing you with the best possible care. In order to achieve this goal, your understanding and acceptance of the policies and financial agreement below is necessary. Please thoroughly review the following and acknowledge your agreement. These policies and fees are subject to change without prior written notice. You will be informed about the updated policies and fees when a request is made for these services. Furthermore, as we cannot always anticipate every need and situation that arises, some policies and fees are not included and will be addressed on a case by case basis.

CONFIDENTIALITY

Everything you discuss with me is held in strict confidentiality. The only person, with whom I may discuss your case, in an effort to ensure my work with you is free from personal bias, would be with a therapeutic supervisor. Your identity however will never be revealed. Please be aware that there are certain conditions in which the law requires that I break confidentiality. These include but are not limited to the following: 1) if you present an imminent danger to yourself 2) if you present an imminent danger to another person 3) if there is reason to believe that child or elder abuse or neglect is present.

APPOINTMENTS

Services are typically provided on an appointment basis, unless the situation is an emergency, and are scheduled directly with the practitioner. Phone calls will be returned as soon as possible. Please be sure to arrive on time for your appointment. If you arrive after the start of your scheduled appointment, you will still be expected to pay for the session in full. Fourty-eight hour notification of appointment cancellation is required. Please be sure to provide a full 48-hour notice for cancellations or a fee for the full session will be charged.

You are free to terminate work with me at any time. However, I do request that if you are considering terminating our work together, that you discuss this with me in a timely way (a minimum of two session before actual termination date), so that we can explore the reasons in depth. Sometimes clients terminate when they are moving into uncomfortable but valuable areas of consciousness and my intention is to help you navigate through these feelings rather than abandon the process at what may be a critical time in your therapy.

PHONE CALLS / EMAILS

There is no charge for phone calls or emails under 10 minutes as these calls are generally routine calls (i.e. appointments). Phone calls or emails over 10 minutes tend to involve therapy issues and a fee may be charged, which also includes phone consultations with other professionals/family members, etc. The fee for these services is $10 per hour (prorated per 15 minutes at $40). Please note email is not confidential.

BILLING AND PAYMENT

No billing can be done with any insurance company. All services are based upon self pay. First appointment must be paid in advance. All payments due at the time of service. Payments can be made with cash or local check. Returned checks fee is $50.00.

FEE STRUCTURE (effective January 1, 2026 rates subject to change without notice)

Package prices are available and provide a better value for clients. Please inquire for current packages. Hourly rates below.

90 minutes couples $245 (David only)

90 minutes couples $315 (David & Bentley)

Inquire about fees for Clare and David
Agreement*

I have read and agree to the Financial Agreement & Office Policies.
Consent to Supervision & Use of Recordings

Please read and answer questions below.
Purpose of Supervision

In order to ensure the highest quality of care, your practitioner participates in professional supervision. Supervision is a process where practitioners meet with senior colleagues and teachers and / or peers to receive guidance, support, and feedback on their work. The goal is to enhance skills and provide the best possible services to clients.

Confidentiality

• Your confidentiality is a top priority.
• In supervision, your practitioner may discuss aspects of your sessions, but identifying information (such as your full name, address, or other personal details) will be removed whenever possible.
• Supervisors are bound by the same professional standards of confidentiality as your practitioner.

Use of Recordings

• At times, practitioners may create video sessions for supervision, teaching & training purposes.
• Recordings benefit the clients by enhancing the quality of care you receive.
• These recordings allow supervisors to provide more accurate and constructive feedback.
• Recordings are optional. You may choose whether or not to give permission for your sessions to be recorded.
• Recordings will be stored securely, used only for supervision, training & teaching purposes.
We understand that my practitioner may present my case in supervision, with my confidentiality protected*

YES
We give permission for our sessions to be video recorded for supervision, teaching & training purposes.*

YESNO
We understand that recordings (if we consent) will be stored securely, used only for supervision, teaching & training purposes.*

YES
Release of Liability

You must acknowledge that you have read, understand, and agree to the Release of Liability by clicking the box below.
PARTNER A - By typing my full name below and sign this form, I am affirming that I have read, understood, and agree to be legally bound by the Release of Liability, Financial Agreement, and Office Policies.

First NameLast Name
Partner A Signature*

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PARTNER B - By typing my full name below and sign this form, I am affirming that I have read, understood, and agree to be legally bound by the Release of Liability, Financial Agreement, and Office Policies.

First NameLast Name
Partner B Signature*

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Payment Options

The first session must be paid in advance. The first session can be paid here or you can request an invoice and we can discuss payment options.
Select Payment Option*

Pay $245 (David only)Pay $315 (David & Bentley)Request Invoice
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REGISTRATION AND RELEASE FORM - COUPLES

CONTACT INFORMATION - PARTNER A

CONTACT INFORMATION - PARTNER B

Relationship Details

Approaches to Healing and Modalities

Financial Agreement & Office Policies

Consent to Supervision & Use of Recordings

Release of Liability

Payment Options