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

  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

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