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KARIS COUNSELLING SERVICES

COUNSELLING & FEE CONTRACT

Counselling will address issues of the whole person, which may include the areas of the emotional, volitional, behavioral, and spiritual aspects of your life. The likely benefits of counselling are the development of a healthier life-style and healthier relationships. You have the right to request that your counsellor explain any part of the counselling process to you.

The counsellee is free at any time to seek other counselling assistance or to not seek any more counselling help without counsellor prejudice. Other counselling options, if any, will be provided at the counsellee’s request. The counsellor or counsellee has the right to terminate the counselling process upon serving reasonable notice and supplying grounds for termination.

Unidentifiable statistical information may be used from your file for reporting purposes. The personal notes of the counsellor and the counsellee’s files are the sole property of Karis Counselling Services.

There are some limitations to professional confidentiality. If your counsellor receives a court order to release information found in your file, if a child under the age of 16 may be in need of protection, or in cases of any threat of harm to yourself or others, your counsellor is required to contact the appropriate authorities with the necessary information.

Those at Karis Counselling Services regularly participate in supervision or peer consultation. Some content (not identifying information) of your session may be divulged in an individual or group/peer supervisory setting.

Your sessions are recorded in the following manner: Notes

FEES

A CANCELLATION FEE for each missed appointment will be assessed at $40.00 unless notice is given 24 hours prior to the set appointment time.

The fee for service is based on our agreed upon rate (please add the amount below).


 

Please complete the form below and click the Submit button to send in your contract.

Name:

Preferred Email Address

Payment Type (please select your method of payment):

If Cheque, please submit your cheque via mail to:

Make cheque out to: Karen Wells
Send to: 940 Alderson Ave Coquitlam, BC V3K1V6

If Credit Card, a paypal button will be emailed to you - please provide your email address:
Email Address:

If Internet Banking, please email your payment to kariscounsel@gmail.com
Also, please provide your email address and preferred password:
Email Address:
Preferred Password:

*I accept responsibility for the cost of counselling services of a rate agreed upon of

Please type your initial below to indicate agreement.
 Yes No

All fees are due when services are rendered unless billing has been approved.

I have read and understand the above counselling and fee contract. Questions and clarifications have been adequately explained. I am in agreement to fully participate in the counselling relationship.

Signed on: (please enter date)

Signature of Counsellee #1 (please type your Full Name which will take the place of a signature):

Signature of Counsellee #2 (please type your Full Name which will take the place of a signature):