Client Disclosure & Support Intake Form
Share your details with an empathetic listener and indicate what kind of support you want.
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Reaching Out
*
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Client Expectations Agreement
Respectful communication; no harassment or threats; appropriate language; attendance and punctuality; cancellation policy; and technology expectations for virtual sessions. Cancellation & Appointment Policy Cornellius Bloom Distribution, LLC Empathetic Listener Services We value your time and are committed to providing each client with compassionate, dedicated support. Please review the appointment policies below. Appointment Cancellations If you need to cancel or reschedule your appointment, please provide at least 24 hours’ notice. Providing advance notice allows us to offer your appointment time to another client in need of support. Late Cancellations Appointments canceled with less than 24 hours’ notice may be subject to a cancellation fee or forfeiture of the session, depending on your service agreement. No-Show Policy A no-show occurs when a client does not attend a scheduled appointment and does not notify Cornellius Bloom Distribution in advance. Clients who miss an appointment without notice may be charged the full session fee, be required to prepay for future appointments, or have future scheduled appointments canceled after repeated no-shows. Late Arrival If you arrive late, your session will still end at the originally scheduled time to respect appointments for other clients. If you arrive more than 15 minutes late, the appointment may need to be rescheduled. Emergency Situations We understand that unexpected emergencies happen. If circumstances beyond your control prevent you from attending your appointment, please contact us as soon as possible. Exceptions may be made at the discretion of Cornellius Bloom Distribution. How to Cancel or Reschedule Appointments may be canceled or rescheduled by phone, email, or through our online scheduling system, if available.
Client Expectations Agreement
*
I agree to the Client Expectations Agreement
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Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
*
Is there anyone we should contact if you are experiencing an emergency?
*
Yes
No
Final Acknowledgement
Please enter your name and the date to confirm your acknowledgement.
Date
*
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Emergency Contact Information Acknowledgement
*
Submit Disclosure
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