Marcia C. Barksdale, LPC, NCC Islands Counseling
805 Holcomb Boulevard Ocean Springs, MS 39564
Appointment: 228 324-5767 Counselor: 228 324-3244
Islands Counseling Effective Date: 06/30/05 LPC # 1408, NCC # 209203
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
• HiIPPA Policy
• Declarations Policy
• Disclosure Policy
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 counseling at Islands Counseling. (parent’s signature)
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 Signature of Counselor 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