I First Name *     Last Name *    by my signature on the next page, I acknowledge that I have read, understand, and agree to informed consent treatment as outlined in the "informed consent for treatment" document.

I First Name *     Last Name *    by my signature on the next page, I acknowledge that I have read, understand, and agree to the limits of confidentiality as outlined in the "limits of confidentiality and privacy practices" document.

I First Name *     Last Name *    by my signature on the next page, I acknowledge that I have read, understand, and agree to the fee disclosure and client payment responsibility agreement as outlined in the "fee disclosure and client payment responsibility agreement" document.

I First Name *     Last Name *    by my signature on the next page, I acknowledge that I have read, understand, and agree to the verification of insurance and submitting billing to your insurance provider as outlined in the "verification of insurance and submitting billing to your insurance provider" document and you agree to allow The Rock Counseling Group to release information to insurance companies as required for billing including electronic billing/ data submission if appropriate. You also agree to authorize payment directly to The Rock Counseling Group by your insurance carrier unless otherwise agreed upon with The Rock Counseling Group.  

I First Name *     Last Name *    by my signature on the next page, I acknowledge that I have read, understand, and agree to terms of appointment reminders, missed appointments, cancellation, and no show fees as outlined in the "Appointment reminders, missed appointments, cancellation fees, and no-show fees" document.

I First Name *     Last Name *    by my signature on the next page, I acknowledge that I have read, understand, and agree to how behavioral health records will be handled as outlined in the "Behavioral Health Medical Records" document.

I First Name *     Last Name *    by my signature on the next page, I acknowledge that I have read, understand, and agree to the information provided regarding contacting my therapist, emergency services, and crisis intervention as outlined in the "Contacting your therapist, Emergency services, and Crisis intervention".