Janell W. Harvey, LPC

    805 Holcomb Boulevard 

Ocean Springs, MS  39564

Appointment: 228 324-5767     Counselor: 228 326-2023

LPC # 0388

harvey.janell@gmail.com     www.islandscounseling.com

CONFIRMATION PAGE

Please check the appropriate boxes below and bring this page in with you to the first session with your counselor.  Fill out the Adult or Adolescent Information Checklist as well.

I have read, understand, and agree to the following concerning Islands Counseling

▪ Cancellation Policy

▪ HIPPA Policy

▪ Declarations and Procedures Policies

_______________________________________________

Client signature                                                        Date

___________________________________________________

Counselor Signature                                                Date

If the client is a minor, the parent or guardian must also sign.

I ________________________________ give permission for my child(ren) to receive 

            (parent’s signature)                                  

counseling at Islands Counseling.  

FINANCIAL AGREEMENT AND AUTHORIZATION FOR TREATMENT

I have been informed of and read the Disclosure and Consent Form and agree to it.  I authorize treatment of the person named below and agree to pay all fees as stated in it. __________________________________________________

Signature of Client or Legal Guardian                      Date

__________________________________________________

Counselor Signature                                                Date

I  have completed and will include with this form the following two forms which are located on the website:

• Client Intake Form
• Adult or Adolescent Information Form