Adult Consent Form
I understand that the staff of Refresh Christian Marriage Counseling and those associated with them are not licensed mental health counselors, therapists, medical or psychological practitioners. I understand that Refresh Christian Marriage Counseling staff offers counseling with a biblical value base. The counselors are board certified with the International Board of Christian Care and with the American Association of Christian Counselors.
I understand that my participation in the counseling process is voluntary and I am free to discontinue attendance at any time. I understand that there is a $135.00 charge for the 1 ½ hour couple-to-couple intake session, or $120 for 1 ½ hour individual intake session. I also understand that for second and subsequent sessions, there will be a $120.00 charge per hourly session for couple-to-couple sessions, and $90.00 charge for individual sessions, to help support Refresh Christian Marriage Counseling. Since Refresh Christian Marriage Counseling is a 501c3 the charge can be counted as a charitable donation by the client. Accepted methods of payment are check, cash, or major credit cards (Visa, MasterCard, American Express, and Discover Payment is expected at the time services are rendered.
Cancellation Policy
We understand that life happens and sometimes schedules change. However, out of respect for our time and other clients, the following cancellation policy applies:
Same-Day Cancellations: If you cancel your scheduled virtual counseling session on the same day of your appointment, you will be charged the full amount of your session.
Cancellations Within 24 Hours: If you cancel your session within 24 hours of your scheduled time (but not the same day), a $75 cancellation fee will apply.
This policy helps ensure availability for those who need support and honors the time set aside for your growth and healing. We appreciate your understanding and commitment.
I understand that after the initial intake session, my counselor will commit to several weeks of brief therapy format to address the issues for which I have sought counseling. After the format has concluded, a re-evaluation will be made concerning future counseling sessions. I understand that the information I disclose in counseling is confidential. Confidentiality is assured unless there is reason to suspect that a child under the age of 18 or an adult over the age 65 is endangered by abuse or I am a danger to myself or others. I understand that I may ask for clarification of any part of this statement.