• You are required to read through the following terms and conditions. When you have reach the end, checking the box will satisfy the agreement to be submitted.


    I hereby consent to treatment by the therapist / coach listed below.

    I understand there is no insurance covering the costs of my treatment. I am responsible to pay for services at the cost of $150 per hour for individuals, and $180 per hour for couples / groups / families. Any appointments not cancelled with 24 hours notice may be subject to a $50 fee.

    I understand there are no guaranteed outcomes for my treatment. My therapist / coach and I will work together to determine my treatment goals and the steps to reach the goals.

    Anything I say in the sessions is confidential UNLESS: written permission has been given for release of information, a court order requires disclosure of some information or if I report or threaten harm to myself or others. My therapist / coach and I will work together as much as possible regarding any disclosure of information.

    I will disclose to the best of my ability information asked of me related to my medical history, my family history, my experiences, and my expectations for our sessions. I will do my best to work with my therapist / coach to create and implement my goals.

    I may stop our sessions at any time. I may ask my therapist / coach any questions regarding our work together and stop the treatment / coaching process until my questions are answered satisfactorily.

    Any complaints or concerns regarding my therapist / coach or treatment will be brought directly to the attention of the therapist / coach.

    If I am a child under the age of 18 my parent(s) will co-sign this form authorizing our working relationship.

  • MM slash DD slash YYYY
  • 951 High Street Suite B Worthington, Ohio 43085
    614.578.5190 www.thecenterforfamilyresolution.com