Type of Service/Treatment

Individual, Couple, Family System, and Group Therapy or Class

Anticipated Length of Service/Treatment

52 Weeks

Participant Choice and Consent for Treatment
I acknowledge that information has been provided to me regarding the alleged benefits and potential risks of receiving treatment services from Mind Form Personal Development.  A representative of Mind Form Personal Development has explained to me the anticipated course of treatment.  I understand that there are other available treatment providers and that I have the choice of selecting other providers to address my needs.  By signing this form I acknowledge that I choose to receive the above noted services through Mind Form Personal Development.  I further understand that this consent is valid for one year and may be withdrawn at any time.

The therapist will work out a session schedule with you.  Please schedule any additional or emergency appointments by texting, emailing or calling the therapist at 919.526.0735.  

Attendance Policy

  • Clients are requested to attend all scheduled appointments.  Please text or email the therapist to inform her of any expected lateness or absence as soon as it is known. 
  • Mind Form Personal Development requires 36 hours notice for cancellation of scheduled services. Appointments can be cancelled by texting, calling or emailing the therapist and receiving confirmation of cancellation.  Participants are responsible for the full price of services not cancelled more than 36 hours in advance.  Once an appointment has been booked, there is a $4.00 cancellation/rescheduling fee regardless of notice given.
  • Within 6 months, if 3 appointments are cancelled without notice to the therapist, no further services will be scheduled.
  • At the time services are scheduled please provide a credit card number. This number will be maintained in written form only and kept in a locked and secured location to be used only in cases of cancellations without 36-hour notice.

Financial Agreement
All clients must pay in full and payment is due at the start of each session.


In order to create a safe environment, representatives of Mind Form Personal Development maintain client privacy and confidentiality.  You are asked to do the same by not disclosing the identity of any clients you see or interact with at Mind Form or any information about them you acquired through joint participation in an event. The therapist will not keep confidential any information that involves keeping you or others alive.  The therapist is also required by law to report any instances of abuse or neglect of children or disabled adults.  Also there is no guarantee of confidentiality for information that is sent to insurance companies. In light of this, you may want to consider whether or under what conditions you use insurance versus paying for therapy on your own.  

Phone Calls
If you need to talk with the therapist at any time other than your scheduled appointment time, you may call 919.526.0735 between the hours of 10:00 am and 10:30 pm.  If the Therapist is available she will answer or return your call.  The first 10 minutes are free.  Additional time will be charged at the rate of her hourly fee. You may leave voice mail for the therapist.  The voice mail is confidential; it is passworded and voice mails are erased after being listened to by the therapist. 

For some clients, writing can be an important part of recovery.  If you would like to email your therapist between sessions in the spirit of journaling and sharing your thoughts, feelings, and experiences via email, the therapist will attempt to read these email(s) before your next appointment and will usually come prepared to discuss what you have shared.  The therapist will rarely email you back, but will talk with you about what you wrote in the session.

The therapist spends about 1.25 hours/week of time outside each session for every 1 hour of time spent in session with clients.  This is about the ratio that is necessary to maintain North Carolina licensing, attend mandatory and otherwise relevant training sessions, compile post-session case notes, perform case conceptualizations, perform weekly scheduling and administrative duties, staff cases with colleagues as is clinically appropriate, and more – all in the interest of providing quality services to clients.  The therapist’s hourly fee for Client sessions is $89.  Family sessions are scheduled for 1.25 - 1.5 hours at this rate.

I have read the Outline of Clinical Practice and I accept responsibility for the financial agreement, attendance policy, and issues of confidentiality.


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Mind Form Representative Signature with Credientials                                  Date

__________________________________________                                 ___________                                                                                                   Client Signature                                                                                             Date

__________________________________________                                 ___________                                                                                                   Parent or Legal Guardian's Signature if Client is Under 18                              Date



This statement was written March 25, 2014.

This statement was reviewed December 4, 2014.

This statement was reviewed May 20, 2015.