Please list all current and former immediate family members and their relationship to client (i.e. bio-parent; step-parent; adoptive parent; full, half, adoptive, or step-sibling). 

Please note the age span of the client when they lived together (i.e. present; life, never, etc.) noting if it was not full-time.

Please list the following the best as you can. We understand that you may not be able answer some of the questions pertaining to the other parent.

Client's Father

Client's Mother

Parent's Marital Status

Family Concerns

Please check any family concerns that your family is currently experiencing.

I hereby give consent for Christian Counseling of South Tampa, LLC, and the staff and employees to treat {clientsName} as a client as of this date, {date}. 

I am the lawful parent/guardian of {clientsName}, and there are no court orders in effect that would prohibit me from conferring the power to consent upon said child.

Confidentiality: All communications between the client and the counselor are confidential. Such information will not be released to anyone, including other agencies, without your written consent. However, Florida State Law requires that the therapist report to the appropriate authorities any suspected sexual abuse, physical abuse, neglect of a minor or serious threat of physical harm to self or others. In addition, if a court orders the therapist to testify, the therapist is required to do so. Other exceptions to confidentiality would be if it were necessary to consult with a supervisor, colleague, or pastor regarding recommendations for treatment. 

Telephone & Emergency Procedures:  Should you need to contact the center, our answering system will receive your call 7 days a week, 24 hours a day. When calling, please leave your name and telephone number where you can be reached for a return phone call. Phone calls will be returned within a 24-hour business day period. If an emergency arises, indicate it clearly in   your message with a clear call back number and follow the directions on the recording in regards to calling 211 or 911.

In the event of an emergency, during or after therapy, the counselor becomes concerned for your safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, he/she will do whatever is needed, within limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, he/she may also contact the person whose name you have provided as your emergency contact.

Payment of Services: A non-refundable deposit is required at the scheduling of your initial intake session equal to one-half the 90- minute session fee. Each counseling session thereafter is 50 minutes. We ask that payment be made prior to each session. Please allow for this in your arrival time by arriving at least 10 to 15 minutes early. Payment may be made payable to Christian Counseling of South Tampa, or CCST, by cash, check or credit card (we accept Visa, MasterCard, American Express or Discover). There is a $35.00 fee for any checks or cards returned for insufficient funds. Requests for calls from your counselor is charged after the first 10 minutes at the normal rate per half hour.

Insurance: Since we currently are not on any insurance panels, should your insurance company reimburse for any out of pocket expense, the appropriate receipt and documentation will be given you to file your insurance claim in order to obtain reimbursement. This does not guarantee reimbursement.

Requests for Psychotherapy Receipts: Requests for psychotherapy receipts for insurance reimbursement purposes are acknowledged by our office within 48 hours of your request. Receipts will then be provided to you within 7 business days, either through USPS, email, or at your next appointment.

Late Appointments: We typically schedule clients on the hour. Therefore, it is necessary to be prompt for your session. Counselors will wait 20 minutes for a client. However, if the client chooses to arrive late, only the remainder of the session will be utilized. If for some reason the therapist is running late, the full scheduled session will still be provided.

Cancellations: Regular attendance will produce the maximum therapeutic benefits. If you must cancel or reschedule, please phone the center no later than 24 hours in advance of your scheduled appointment. Our system records the date and time of your call. The full amount of your counseling fee will be charged for cancellations or missed appointments with less than 24- hour notification. Services will be discontinued, or a prepayment required, if there are two missed scheduled appointments, or if there are two consecutive late cancellations. Your cooperation in this regard will be greatly appreciated. At your request, text message reminders will be sent to you 24 hours in advance. However, due to technological issues that sometimes occur the text message reminders are only considered a courtesy reminder. These reminders can not be depended upon for timely cancellation of your appointment.

Dual Relationships: Not all dual or multiple relationships are unethical or avoidable. Therapy never involves any dual relationship that impairs the therapist’s objectivity, clinical judgment or can be exploitative in nature. It is important to realize that in some areas multiple relationships are unavoidable. The counselor will never publicly acknowledge working with you without written permission. Neither will you be accepted as a client if the counselor feels there is a significant dual or multiple relationship in existence. It is your responsibility to advise the counselor if any such relationship becomes uncomfortable for you in any way. The counselor will always listen and provide feedback and will discontinue the dual relationship if you find it is or may interfere with the effectiveness of the therapy or your welfare and of course you may do the same at any time.

Social Networking & Internet Searches: The counselors of the practice do not accept friend requests from current or former clients on social networking sites such as Facebook. The reason for this is that we believe that adding clients on these sites and or communicating via such sites is likely to compromise their privacy and confidentiality. For this same reason, we ask that clients do not communicate with the counselors via interactive or social networking sites.

Court Fees and Practice:  Although the therapist’s responsibility to you may require involvement in conflicts between you and another if you are in couples’ therapy/family therapy or have a child in therapy, we ask that you will treat anything that is said in session with the therapist as confidential. Neither party will attempt to gain advantage in any legal proceeding between the two of you from therapeutic involvement with another. In particular, you agree that in any such proceedings, neither party will ask the therapist to testify in court, whether in person, or by affidavit. You also agree to instruct your attorneys not to subpoena the therapist or to refer in any court filing to anything he/she may have said or done.

Note that such agreement may not prevent a judge from requiring the therapist’s testimony, even though he/she will work to prevent such an event. If he/she is required to testify, the therapist is ethically bound not to give his/her opinion about either party’s suitability. If the court appoints an evaluator, guardian ad litem, or mediator, he/she will provide information   as needed (if appropriate releases are signed or a court order is provided), but the therapist will not make any recommendation about the final decision. Furthermore, if the therapist is required to appear as a witness, the party responsible for his/her participation agrees to reimburse him/her at the rate of $275 per hour, including preparation time prior to court, time away from office/other clients on court date, and all related correspondence with third parties. A retainer fee of $1100 will be due one week in advance of your court date. The retainer fee only secures your court date on our calendar
and will expire after that one date passes. It also includes up to 4 hours of time at $275/hour and you will be responsible for any fees exceeding four hours. In the event, time spent is less than four hours, the retainer fee will be returned at a prorated rate. All fees are due no later than 30 days after court date and will be sent to collections if unpaid at that time.     

Christian Counseling: All beliefs are accepted in this center; however, the counselors adhere to the faith that there is only one God who sent His Son, Jesus Christ, to atone for our sins and provide a way for each individual to have a personal relationship with God.  The Bible is the infallible, inerrant Word of God.  All theoretical stances and theories practiced in this office align with the principles taught in the Bible.  References to specific scripture and prayer are commonly used in the sessions. Please discuss your comfort level with your counselor regarding any concerns you may have with these practices.                 

I have read the above information and voluntarily request counseling services with Christian Counseling of South Tampa. I agree with these terms and conditions.

Prior to beginning treatment, it is important for you to understand the therapist’s approach to child therapy and agree to some guidelines about your child’s confidentiality during the course of his/her treatment.  The information herein is in addition to the information contained in the Patient-Therapist Agreement. Under HIPAA and the APA Ethics Code, the therapist is legally and ethically responsible to provide you with informed consent. As we go forward, the therapist will try to remind you of important issues as they arise. Therapy is most effective when a trusting relationship exists between the psychologist and the patient. Privacy is especially important in securing and maintaining that trust. One goal of treatment is to promote a stronger and better relationship between children and their parents. However, it is often necessary for children to develop a “zone of privacy” whereby they feel free to discuss personal matters with greater freedom. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy. By signing this agreement, you understand the therapist will not be sharing the content of what your child discloses or their records without your child’s consent.

It is our policy to provide you with general information about treatment status. If it is necessary to refer your child to another mental health professional with more specialized skills, he/she will share that information with you. The therapist will tell you if your child does not attend sessions. At the end of your child’s treatment, a treatment summary that will describe what issues were discussed, what progress was made, and what areas are likely to require intervention in the future will be provided.

If your child is an adolescent, it is possible that he/she will reveal sensitive information regarding sexual contact, alcohol and drug use, or other potentially problematic behaviors. Sometimes these behaviors are within the range of normal adolescent experimentation, but at other times they may require parental intervention.  If the therapist ever believes that your child is at serious risk of harming him/herself or another, you will be informed.

Although the therapist’s responsibility to your child may require his/her involvement in conflicts between the two of you, your agreement that his/her involvement will be strictly limited to that which will benefit your child. This means, among other things, that you will treat anything that is said in session with the therapist as confidential. Neither parent will attempt to gain advantage in any legal proceeding between the two of you from therapeutic involvement with your children. In particular, you agree that in any such proceedings, neither parent will ask the therapist to testify in court, whether in person, or by affidavit. You also agree to instruct your attorneys not to subpoena the therapist or to refer in any court filing to anything he/she may have said or done.

Note that such an agreement may not prevent a judge from requiring the therapist’s testimony, even though he/she will work to prevent such an event. If he/she is required to testify, the therapist is ethically bound not to give his/her opinion about either parent’s custody or visitation suitability. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, he/she will provide information as needed (if appropriate releases are signed or a court order is provided), but the therapist will not make any recommendation about the final decision.   Furthermore, if the therapist is required to appear as a witness, the party responsible for his/her participation agrees to reimburse him/her at the rate of $275 per hour, including preparation time prior to court, time away from office/other clients on court date, and all related correspondence with third parties. A retainer fee of $1100 will be due one week in advance of your court date. The retainer fee only secures your court date on our calendar and will expire after that one date passes. It also includes up to 4 hours of time at $275/hour and you will be responsible for any fees exceeding four hours. In the event, time spent is less than four hours, the retainer fee will be returned at a prorated rate. All fees are due no later than 30 days after the court date and will be sent to collections if unpaid at that time.                 

I have read and understand this contract and agree with its terms in it's entirety. 

We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records.  Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used.  If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.

1. The patient understand and agrees to allow this office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care.  As an example, the patient agrees to allow this office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment.  Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.

2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections.  The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI.  Our office is obligated to agree to those restrictions only to the extent they coincide with state and federal law.

3. A patient’s written consent need only be obtained one time for all subsequent care given the patient in this office.

4. The patient may provide a written request to revoke the consent at any time during care.  This would not affect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented.

5. Our office may contact you periodically regarding appointments, treatments, products, services or charitable work performed by our office.  You may choose to opt-out of any marketing or fundraising communications at any time.

6. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office.  We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them.

7. Patients have the right to file a formal complaint with our privacy official and the Secretary of HHS about any possible violations of these policies and procedures without retaliation by this office.

8. Our office reserves the right to make changes to the notice and to make the new notice provisions effective for al protected health information that it maintains.  You will be provided with a new notice at your next visit following any change.

9. This notice is effective on the dated stated below.

10. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the therapist has the right to refuse to give care.

For further information regarding this notice, please contact our office at 813.254.3200.

As a client of Christian Counseling of South Tampa, you are responsible for full payment at the time of services. As a convenience to you, we will automatically charge your designated credit card below on the day of service.

For missed or canceled appointments where 24 hours’ notice is not given, you will be charged the full fee for your missed appointment.

I agree to the above terms and authorize you to charge my credit card.