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Hallysqueez Counseling

COUNSELING SESSION FORM

Client Information:

Name

Email

Phone number

Symptoms and Challenges:

What symptoms or challenges are you experiencing? (Check all that apply)

What symptoms or challenges are you experiencing? (Check all that apply)
A
B
C
D
E

Presenting Issues

What brings you to counseling at this time?

What are your goals for counseling?

Session Information(please fill this 2days before appointment):

Date of session

Time of session

Duration of session

Duration of session
A
B
C

Session Type

Session Type
A
B
C

What mode of communication do you preferre?

What mode of communication do you preferre?
A
B
C
D

History

Briefly describe your relevant history (e.g., past counseling, significant life events)

Current Support System:

Who are the people in your support system?

How do you currently cope with stress or difficult emotions

Payments

-The fee for each counseling session is 8,000/30min/per person .
-Payment is due at the time of each session.
- I understand that I am responsible for paying for each session, regardless of my insurance coverage.

Please ensure you sign a consent form before you begin counseling.

Confidentiality:

- I understand that all information disclosed during the Services will be kept confidential.
- The Therapist will not disclose any information to anyone without my written consent, except as required by law.

_Limits of Confidentiality:_

- I understand that the Therapist may be required to disclose information to prevent imminent harm to myself or others.
- I understand that the Therapist may disclose information to comply with legal requirements or to protect the Therapist's rights.

_Acknowledgement:_

- I acknowledge that I have read and understood this Consent Form.
- I acknowledge that I am aware of the fee and payment terms.
- I acknowledge that I am aware of the confidentiality and limits of confidentiality.

Client Signature/ Date

Signature