Southeast Professional Counseling
920 Blankenbaker Pkwy., Louisville, KY 40243
Parental Consent and Release
Minor’s Name: _______________________________
I, _________________________________________, parent/guardian of the above-named minor, hereby permit
___________________________________, counselor at Southeast Professional Counseling, to counsel the abovenamed minor.
I hereby release and discharge any and all individuals providing counsel to the above-named minor in
connection with the Southeast Professional Counseling from any and all claims, demands, actions,
damages, losses or liabilities of any kind which I now have or shall or may have by reason of the
Southeast Professional Counseling.
____________________________________________________________
Signature
____________________________________________________________
Date
SOUTHEAST PROFESSIONAL COUNSELING
920 Blankenbaker Parkway, Louisville, KY 40243 – Phone: 502-253-8425
Client Agreement Form
We are pleased that you have chosen to contact the Southeast Professional Counseling. As part of our effort to
provide quality Christian counseling, we want to clearly inform you of some of our basic policies. Please take a
few minutes to carefully read over the agreement and sign at the bottom.
Our Staff: Each counselor at this center has completed a master's degree, or beyond. In addition to their
educational and clinical training, counselors are committed to a deepening personal walk with Christ.
Time Factors: In efforts to be good stewards of our time and resources, it is our goal to assist you as effectively
and efficiently as we can. Sessions will last for approximately 50 minutes. Please be prompt, as we will strive to
be.
Fee Structure:
(Reviewed Annually)
 Psychiatrist: $225 for initial evaluation (90 minutes). A maximum of $90 for ongoing office visits (2030minutes)
 Counselors Fee: Base $90 per session
Fee per Session: $__________
Provider: _____________________________
Client Initial: __________
If you need to cancel a session, we ask that you give us at least 24 hours advance notice
(except in cases of an emergency). There will be a charge for late cancellations or not
showing up for appointments. The charge will be ½ of the established fee per session.
Client Initial ______________
Although we do not take third party payments, insurance companies may reimburse you for sessions with a
psychiatrist or certified counselor. We can provide a statement you can submit to your insurance carrier.
Lengthy telephone consults may be charged as a session-especially when they replace a scheduled session.
Confidentiality: Our counselors seek to honor clients by maintaining strict confidentiality. The few exceptions to
this would include disclosures made with your permission or when the counselor is under legal obligation to
contact appropriate authorities. We are required by law to inform appropriate authorities or agencies when we
obtain information that would indicate that someone is in danger of harm (i.e. if you threaten to harm/kill yourself
or another person, or if you reveal information relative to child abuse/neglect or spouse abuse, elder
abuse/neglect). Any questions you may have concerning this policy can be discussed with your counselor.
Client Initial __________
Acknowledgement and Release
I have read, understand and will comply with the above policies as terms for my counseling. I hereby release and
discharge any and all individuals providing counsel to in connection with the Southeast Professional Counseling
from any claims, demands, actions, damages, losses or liabilities of any kind which I now have or shall or may have
by reason of this Counseling Center.
_____________________________________________
Signature
________________________________________
Print Name
__________________
Date
Care Ministry
Southeast Professional Counseling
Client Information Form for Children/Teens
CONFIDENTIAL
Parent/Guardian’s Information
Parent/Guardian’s Names_________________________________________________________ Date_____/______/________
Current Address________________________________
Daytime Telephone_________/________/_______________
_______________________________________________
Evening Telephone_________/________/________________
Current Marital Status (please check one)
Cell Phone _________/__________/____________________
__Single __Married __Divorced__Widowed __Separated
Email (optional)_____________________________________
Previous Marriages__Yes___No
Occupation_________________________________________
Circle all #’s where we may leave a message
Place of Employment_________________________________
Are there any legal concerns (i.e. court related issues, custody, etc…)? ______________________________________
________________________________________________________________________________________________
Do you have legal custody of the client? ___Yes ___No (If no, please see counselor before continuing).
Client’s Information
Name________________________________________________________ Age_______ Gender M or F Birthdate ___ /___/____
School____________________________________ Grade__________Place of Employment_______________________
Please provide the following information about the client’s siblings from oldest to youngest: (Please use the back if more space
is needed)
Name____________________________ Age_____Birthdate_______/______/______ Biological siblings?____________
Name____________________________ Age_____Birthdate_______/______/______ Biological siblings?____________
Name____________________________ Age_____Birthdate_______/______/______ Biological siblings?____________
Name____________________________ Age_____Birthdate_______/______/______ Biological siblings?____________
Was the client raised by anyone other than his/her biological parents?_____Yes______No
If yes, then who_____________________________________________________________________________________
Religious Affiliation
Are you connected to a specific church?_____ If yes, name of church:________________________________________
Are you a 1) Member_____ 2) Attendee______
How are you connected in your spiritual community? ______________________________________________________
__________________________________________________________________________________________________
TURN OVER TO PAGE 2 ->
Please circle all words or phrases below that describe the client’s current religious experience.
not religious
born again
closed toward God
God is a good father
conflicted
curious but skeptical
charismatic
open to God
God is a harsh father
confused
curious and hopeful
stagnant
God is a friend
God knows me
doubting
seeking God
growing
God feels distant
God loves me
other___________
Medical History
Pediatrician______________________________________________________ Phone_________/_________/_________________
Please provide the following information about any prescription medications currently being taken:
Name______________________ For____________ Dose______ Times per day______ Date prescribed____________
Name______________________ For____________ Dose______ Times per day______ Date prescribed____________
Recent Weight Change: Lost________
Gained___________
Date of last physical exam_________/_________/_________
General physical condition______________________________ Current physical problems________________________
__________________________________________________________________________________________________
Is the client currently under psychiatric care? _____ Yes_____No
Psychiatrist___________________________________________________________Phone_____/_________/_______
Any hospitalization(s) for a psychological problem? _______ Yes________No
Any history of self-harming (i.e. cutting, etc)? ______Yes______No
Any history of suicidal thoughts/intent? ______Yes______No Has the client ever attempted suicide?______Yes______No
Person to contact in an emergency____________________________Relationship to client_________________________
Their phone numbers: Home_________/_________/_________ Cell_________/_________/___________
Desire for Counseling
By whom were you referred for counseling?_______________________ Relationship to you_______________________
Have you sought counseling from a counselor, pastor, therapist, psychologist, or psychiatrist before? ____Yes_____No
If so, for what reason? _______________________________________________________________________________
Name of counselor______________________________________________________ Last visit?______/______/_______
Outcome__________________________________________________________________________________________
Reason you are seeking counseling today_________________________________________________________________
__________________________________________________________________________________________________
Desired outcome____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________