Client Registration Form


Patient Name:


Street Address:


City, State, Zip Code:




Email Address:


Mobile Phone:


Primary Physician:

Psychiatrist (if any):


Insurance Provider:


Emergency Contact Person:


Emergency Contact Phone:



Therapist Information and Disclosure:


Training and Degrees: I am a PhD ABD candidate at Seattle Pacific University and received my Masters of Arts in Counseling Psychology in 2007 from Reformed Theological Seminary in Orlando, Florida. I completed my Medical Family Therapy Training at Seattle Pacific University. I am a Licensed Mental Health Counselor in the State of Washington.

Counseling Orientation: I view the evaluation process as forming an alliance with you to explore the nature of your successes and struggles. During the session, I will ask you about your personal understanding of yourself and the way you desire to live your life. I will also ask about family and health history as well as your psychological development. In some cases, talking about your personal experiences can prompt you to connect with past wounds. There are multiple techniques we can engage these wounded places and look for places of healing.

Billing and Insurance Information: The fee for a session is $100.00 per 50-minute session. If you want to bill your insurance, I will give you a coded receipt every four session for you to turn in to your insurance. I do not file insurance for you.

Confidentiality: There is a legal privilege in this state protecting the confidentiality of the information that you share with me. As a professional, I can assure you that I strive to maintain the strictest ethical standards of confidentiality.

There are legal exceptions to confidentiality. The following situations are those in which the information you have shared with me may be shared with others.

1) The client gives written permission to share confidential information.

2) Anything that suggests a crime or harmful act.

3) If the client is a minor, and there is indication that she/he was the victim or subject of a crime.

4) The client brings charges against the counselor.

5) In response to a subpoena.

6) As required under chapter 26.44 RCW.

When it is possible, we will discuss any exceptions to confidentiality as they arise.

Consultations: I regularly consult with other professionals regarding clients with whom I am working. This allows me to gain other perspectives and ideas as to how to best help you reach your goals. These consultations are obtained in such a way that confidentiality is maintained.

Scheduling Appointments: Please be mindful and let me know of any cancellations at least 24 hrs before the appointment. If you cancel your appointment at the last minute, you will have to pay for the session. Please note, general emergencies and illness are accepted and will not be charged.

State Information: Counselors practicing counseling for a fee must be registered or certified with the department of health for the protection of the public health and safety. Registration of an individual with the department does not include recognition of any practice standards, nor necessarily implies the effectiveness of any treatment. The purpose of the Counselor Credentialing Act (Chapter 18.19 RCW) is (A) To provide protection for public health and safety; and (B) To empower the citizens of the State of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct.


Unprofessional Conduct: The brochure called "Counseling or Hypnotherapy Clients" lists ways in which counselors may work in an unprofessional manner. If you suspect that my conduct has been unprofessional in any way, please contact the Department of Health at the following address and phone number:

Department of Health, Counselor Programs

P.O. Box 47869

Olympia, WA 98504-7869


Contacting Me by Phone: You may leave me a message at 407.595.7999 or email me at I will check these messages on a regular basis. Please limit your phone conversation and email needs to appointment scheduling and emergencies.

Emergencies: If you are in an emergency and cannot reach me, please call one of the following numbers for help: General Emergencies 911 or Crisis Clinic 800.244.5767 or 206.461.3222

I have read and understand the information presented in this form.


Signature: _______________________________________


Date: __________________________




This is to authorize that the information specified below regarding the above person be disclosed between:


Client Name:

Date of Birth:

Specific Information to be Disclosed: Psychological Evaluation

I understand that my records may contain information relating to mental health issues. I also understand that my written consent is required to release any health care information relating to testing, diagnosis, and/or treatment for HIV (AIDS virus),

psychiatric disorders/mental health, and/or drug and/or alcohol use. If I have been tested, diagnosed, or treated for any of these things, you are specifically authorized to release all health care information relating to such diagnosis, testing, or treatment. This authorization prohibits further use of disclosure of the information being released beyond the specific limits of this consent. I understand that I may cancel this authorization at any time, except to the extent that the action has already been taken. Unless canceled earlier by me, this authorization will expire in ninety (90) days from the signature date.

Signature: _____________________________________ Date: __________________

Client ______ Parent ______ Legal Guardian ______