Welcome! Thank you for choosing Cornerstone—we look forward to working with you.

Please note: The following forms are completed through Jotform and shared with your interventionist via email prior to your appointment to support culturally responsive care that reflects your background, values, and support systems.

We recognize that sharing personal information in written or digital formats may feel uncomfortable or not aligned with your preferences. You are not required to provide information in a way that does not feel appropriate to you.

Please be advised that Jotform and standard email are not HIPAA-compliant forms of communication, and confidentiality cannot be guaranteed. By proceeding, you acknowledge and accept these risks.

If you prefer not to submit information through Jotform or email, you may leave sections blank or request an alternative method (e.g., verbal intake or supported completion). Please contact us at appointments@cornerstoneintervention.com to discuss options.

All clients are required to complete this form prior to scheduling or attending sessions.

Exception: Clients whose sessions are fully covered through a refugee partnering organization are not required to complete this form. If this applies to you, please indicate below:

All clients whose sessions are covered by any other partnering organization (non-refugee programs) are still required to complete this form and are subject to the policy outlined below.

To ensure fair scheduling and respect for interventionists' time, cancellations and rescheduling requests must be submitted at least 24 hours prior to the scheduled appointment time. When a session time is reserved, it is held specifically for you.

If an appointment is rescheduled, the newly selected appointment time must be scheduled no fewer than 48 hours in advance and may not occur within 48 hours of the time the change is made.

A no-show occurs when a client does not attend a scheduled appointment and does not provide notice.

Clients whose sessions are covered by a partnering organization (other than a refugee agency) are granted one courtesy exception for any of the following without charge: no-show, cancellation within 24 hours of the appointment, or a reschedule request within 24 hours of the appointment. For the first occurrence, the session will remain free of charge.

After the one courtesy exception has been used, any additional late cancellations, late reschedules, or no-shows will no longer be free of charge. The client will be responsible for the full cost of the scheduled session (one hour, or more if scheduled for longer than one hour) at the applicable rate:

$125 per hour- Individual Sessions

$130 per hour - Couples Sessions

$135 per hour - Family Sessions

(rates include a $5.00 per hour processing fee).

Clients who are not covered by a partnering organization are not eligible for a courtesy exception. All late cancellations, late reschedules, or no-shows will be charged for the full scheduled session (one hour, or more if scheduled for longer than one hour) at the applicable rate:

$125 per hour - Individual Sessions

$130 per hour - Couples Sessions

$135 per hour - Family Sessions

(rates include a $5.00 per hour processing fee)

*or your agreed-upon session rate if receiving financial assistance.*

Fees may be waived in cases of medical emergencies, severe weather conditions, or unexpected family emergencies. All exceptions are at the interventionist's discretion.

Any outstanding cancellation or no-show fees must be paid prior to scheduling future appointments unless otherwise arranged.

I understand and agree to the cancellation, rescheduling, and no-show policy outlined above. I acknowledge that reserving an appointment time is a commitment and that late cancellations or missed sessions impact both my care and the availability of services for others

All clients are required to complete a credit card authorization form prior to scheduling or attending sessions.

Exception: Clients whose sessions are fully covered through a refugee partnering organization are not required to complete the credit card authorization portion of this form. If this applies to you, please indicate below:

For clients whose sessions are covered by any other partnering organization (non-refugee programs), a credit card authorization form is still required and must be kept on file. In these cases, your card will not be charged for sessions as long as you remain in compliance with the cancellation and rescheduling policy. However, fees may be charged in accordance with the policy if applicable.

Sessions are charged prior to the scheduled appointment time. If the payment method on file is declined, invalid, or otherwise unable to be processed, the appointment may be canceled or rescheduled until a valid form of payment is provided. If you reschedule in accordance with the cancellation/rescheduling policy, or cancel due to a qualifying emergency and have already been charged, the payment will be applied as a credit toward a future session. If you choose to discontinue services, any remaining credit will be refunded.

Please see our current rates for sessions below:

$125 per hour - Individual Sessions
$130 per hour - Couples Sessions
$135 per hour - Family Sessions

(Rates include a $5.00 per hour processing fee.)

We do not accept insurance. If you are experiencing financial hardship, you may request a financial aid application by emailing finance@cornerstoneintervention.com to determine eligibility for a reduced rate.

Please note: You must enter the full fee for your first session below. The rates listed below include the $5.00 processing fee. If you have an approved financial aid agreement with Cornerstone, please enter your agreed-upon sliding scale rate.

If you were referred by a non-refugee partner agency, please enter $1. You will not be charged this amount. We will keep a card on file only in the event of a cancellation policy violation.

$125 per hour – Individual Sessions

$130 per hour – Couples Sessions
$135 per hour – Family Sessions

(please do not include decimals, or put a 0 value)

Cornerstone recognizes the value of outside support in strengthening relationships and fostering long-term emotional and relational wellbeing. Interventionists are available to assist in this process. Services are provided on an as-needed basis, and referrals to external agencies and/or licensed mental health professionals may be made when appropriate.

All services are confidential. Information disclosed to an Interventionist or related professional will not be shared with third parties without your written authorization, except as required or permitted by law. It is important that you understand the limits of confidentiality, which include, but are not limited to, the following:

1) Situations in which there is a reasonable belief that you or another individual may be at risk of harm, including risk of harm to self or others

2) Situations involving suspected abuse or neglect of a child, elder, or vulnerable individual, in accordance with mandated reporting requirements under New Jersey law, which may require disclosure to appropriate authorities

3) Circumstances in which disclosure is required by law, including but not limited to court orders, subpoenas, or other legal proceedings

4) Circumstances in which Interventionists consult with other professionals for the purpose of providing high-quality care; such consultations are conducted in a manner that protects client privacy to the extent possible

Please note that Cornerstone provides alternative therapeutic intervention services focused on emotional and relational wellbeing. These services are not a substitute for licensed mental health treatment. Referrals to licensed professionals, including LMFTs and other qualified providers, are available upon request or when clinically indicated.

Please note: For all questions below, if a question does not apply to your situation or you are uncomfortable answering, you may write 'N/A.'