Counseling/Clinical Client Contact

Client Name

First NameLast Name

I wish to be contacted in the following manner (please check all that apply):

Cell Phone

Okay to leave a message with detailed informationLeave message with call back number onlyDo not call or leave message hereIf text messaging becomes available as a means of contact, I would like to receive reminders via text.

Cell Phone #

Area CodePhone Number

Work/Home Phone

Okay to leave a message with detailed informationLeave message with call back number onlyDo not call or leave message here

Work Phone

Area CodePhone Number

Written Communication

Okay to mail to my home addressOkay to mail to my work addressDo not mail me

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If you can’t make an appointment, please be sure to contact SARC at least 24 hours prior to your appointment. Due to high demand and the limited availability of counseling appointments, if you miss two appointments in a row, your appointment time will no longer be able to be held for you and will be offered to another client waiting to receive services.

If you do not have any scheduled appointments for a thirty day period, your counselor will make a reasonable attempt to contact you for three weeks. If your counselor is unable to reach you by phone after three weeks, the counselor will send a letter to a safe address that you have provided above. If you do not respond by the date given in the letter, your case will be closed. If you contact us after this time
and there is a waitlist, you will be seen based upon availability of therapists.

Please let your counselor know if there are any changes in the address or the telephone number(s) above.

______________

SARC is happy to provide you with a phone call to remind you about upcoming appointments.

Please call this number to remind me about my appointment. I acknowledge that this is a safe number to call and a message can be left at this number. (Optional)

Phone Number

Area CodePhone Number

I agree that I have read the above cancellation policy and that the above methods of communication can be used. This form will be valid for the duration of participation in Clinical Services at SARC but I can amend it at any time.

Client Signature / Date

Clear

Counseling/Clinical Client Contact Form / Cancellation Policy

Cancellation Policy