Intake (Adult)

Agreement & Consent forms

Please correct the errors described below.

Counseling Expectations:

Our goal is to partner with our clients in achieving their goals. Clients begin services weekly basis. After your needs are improving, the frequency of your appointments are scheduled on a bi-weekly basis. During the final stages of your treatment or therapy, your sessions will be scheduled to monthly sessions.

All forms or letters that are requested by our clients to be completed by our clinical professionals will be charged at the clinician's full session rate. If your session goes over the allotted time there will be an overcharge of $50 per every 15-minutes. There is a $50 returned check fee for any payment returned by your bank.

Our office requires a 24-hour notice prior to canceling or rescheduling an appointment. To avoid a full session charge for a late cancellation or missed appointment, please contact us 24 hours before the scheduled session.

Psychoeducational Testing:
$3,300 (This cost may not be reimbursed by your insurance provider)

ADHD, Autism Spectrum Disorder, Dyslexia, Learning Disabilities

Testing fee covers 4-6 hours of testing, testing results session, 504 Plan/IEP, advocacy campus visit, & test report with diagnosis (when applicable), along with clinical & educational recommendations.

Records and Confidentiality:
Your mental health record is accessible to you within 15 business days of your written request.A fee of $45.00 will be charged for the first 25 pages of the record and additional pages will be at a rate of $1.00 per page.

Court attendance and testimonies:
We are not trained custody counselors nor are we expert witnesses.

However, if you chose to engage us in a legal matter, there is a non-refundable retainer fee of $2,500 due at the time the subpoena is received by FHC. The retainer is used for a court appearance ($250/hr) to block out time to attend and prepare for your court date - whether we are called on the stand or not or the court case is cancelled.

If the amount of time in court surpasses the single day appearance covered by the prepaid retainer, you will be charged at the agreed upon $250/hourly rate. Additional time spent preparing for ANY attorney’s requests including but not limited to: preparing the release of client records, any notarization costs, interviews, responding to ANY attorney’s emails or phone calls at the $250 hourly rate.

Additionally, if a subpoena is issued to our company for ANY legal matter, you agree to accept and assume financial responsibility for the payment of the $2,500 retainer fee and your primary payment method will be charged at the time we receive the subpoena.

Electronic Communication:

Although our sessions may be very delicate in nature, both emotionally and psychologically, please keep in mind our relationship is professional rather than personal. Please use your best judgement and reserve all calls for times you are unable to wait until your next session. If you would like to speak with your therapist before your next scheduled session, please contact the office to set up a telehealth (phone/ZOOM) or in-person session (normal session rate applies).

Termination of Services:
You may choose to end our counseling relationship at any point for any reason. If you miss/cancel 2 consecutive sessions, the therapist may remove you from their schedule to offer their services to another family. You may be given a referral for a therapist available outside of our practice.

Thank you for choosing to begin your care at Forever Hope Counseling & Educational Services, LLC….

By typing name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.


Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:

Duty to Warn and Protect

When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

Abuse of Children and Vulnerable Adults

If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a client (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.

Prenatal Exposure to Controlled Substances

Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.


Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.

By signing below, I agree to the above limits of confidentiality and understand their meanings and ramifications.

By typing name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.




Effective date: July 8, 2014

Forever Hope Counseling & Educational Services, LLC will only release information in accordance with state and federal laws and the ethics of the counseling profession.

This notice describes Forever Hope Counseling & Educational Services, LLC’s policies related to the use and disclosure of the client’s healthcare information. Use and disclosure of protected health information for the purposes of providing services. Providing treatment services, collecting payment, and conducting healthcare operations are necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes.


  • Provide, manage, coordinate care with other healthcare professionals.

You have the right to revoke or cancel this authorization at any time, except: (a) to the extent information has already been shared based on this authorization; or (b) this authorization was obtained as a condition of obtaining insurance coverage. To revoke or cancel this authorization, you must submit your request in writing to your mental health professional and your insurance company, if applicable.

  • Once the information about you leaves this office according to the terms of this authorization, this office has no control over how it will be used by the recipient. You need to be aware that at that point your information may no longer be protected by HIPAA.
  • Special Instructions for completing the authorization for the use and disclosure of Psychotherapy Notes. HIPAA provides special protections to certain medical records known as “Psychotherapy Notes”. All Psychotherapy Notes recorded on any medium (i.e., paper, electronic) by a mental health professional (such as a psychologist or a psychiatrist) must be kept by the author and filed separate from the rest of the client’s medical records to maintain a higher standard of protection. “Psychotherapy Notes” are defined under HIPAA as notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and are separate the rest of the individual’s medical records. Excluded from “Psychotherapy Notes” definition are the following: (a) medication prescription and monitoring, (b) counseling session start and stop times, (c) the modalities and frequencies of treatment furnished, (d) the results of clinical tests, and (e) any summary of: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

My signature indicates I understand HIPAA Authorizations and a separate mental health information disclosure form must be signed to grant permission to discuss protected client information.

By typing name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Debit/Credit Card Authorization

Forever Hope Counseling requires a credit card on file to secure services with our therapists. Please inform the front desk before your sessions begin if you have a preference to pay with cash or check.

By signing this form, you authorize FOREVER HOPE COUNSELING & EDUCATIONAL SERVICES, LLC to charge this card for clinical, academic, or behavioral services provided for -

This card will be charged for any fees related to these services such as: missed appointments or same-day cancellations.

We are unable to schedule appointments with your therapist if there is a balance on your account.

By typing name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Informed Consent for Teletherapy Services

The following information is provided to clients who are seeking Teletherapy services. This document covers your rights, risks and benefits associated with receiving services, my policies, and your authorization. Please read this document carefully, note any questions you would like to discuss before you agree to sign.

Forever Hope Counseling uses ZOOM for interactive video, which complies with HIPAA standards requiring 256-bit AES encryption.

Client Responsibilities for Teletherapy Services:

  • The virtual sessions can only be conducted while the client is within the state of TEXAS.
  • The virtual sessions must be conducted on a Wi-Fi or ethernet (not mobile) network for the best connections and to minimize disruption.
  • Only communicate through a device that you know is safe and technologically secure (e.g. has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.) Do not use “auto-remember” names and passwords.
  • If you conduct a Teletherapy session at your place of employment, make sure you have checked your company’s policy before using a work computer for personal communication.
  • As the client, you are responsible for finding a private, quiet location where the sessions may be conducted.
  • Sessions are not able to take place if other individuals are present in your location.
  • Your therapist is required to verify your identity and location at the start of each session.


I agree to take full responsibility for the security of any communications or treatment on my own computer or electronic device and in my own physical location.

I understand that there will be no recording of any of the online sessions and that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law.

Consent for Teletherapy Services Treatment:

I voluntarily agree to receive online therapy, parent, couples or family therapy services including an assessment, continued care, treatment, and/or other services and furthermore authorize FOREVER HOPE COUNSELING & EDUCATIONAL SERVICES, LLC to provide such care, treatment or services as are considered necessary and advisable.

By typing name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Client Information -

Please answer all of the following or complete as much as possible .

Spouse's Information

Emergency Contact

Biological Family Mental Health History

Wellness & Health

Your information will be encrypted.