consultation form – The Owen Center

Counseling Agreement

Before you enter your information, please take a moment to view the counseling agreement. To read over the agreement CLICK HERE. By selecting “Yes” in the following question, you acknowledge that you have read over and agree with the Counseling Agreement. If you have any questions about this, please call our office or email us at office@theowencenter.com.

Have you read and agree to the Counseling Agreement?*

Yes
No

By selecting "Yes" you acknowledge the following:*

– You understand the counseling agreement. – Your counselor is obligated by state law to report any incidents of suspected or obvious child abuse or neglect. – Your counselor may ask your permission for another counselor/perspective counselor to sit in a session. – Your counselor might be required to divulge information to appropriate civil authorities if there is an indication that you or someone else might otherwise be harmed or be at risk of abuse or neglect.

Yes
No

Personal Information

Name*

First Last

Date

Birthdate

Gender

Address (street, city, zip)

Email*

Phone #*

Marital Status:

Were you referred to us by someone? If so, who?

Religious Affiliation and Current Church:

In a few sentences, please let us know why you would like to meet with a counselor.

How do you expect counseling to help your present situation or condition?

Do you have someone you can talk to about personal issues in your life? (If yes, who?)

Place of employment (if applicable)

Are you currently in school? If yes, where and what year are you?

Have you ever been in counseling or therapy before? If yes, what was the outcome of that experience?

Name of Spouse (If applicable):

Is there anything else that may be helpful for us to know before the first appointment?

Emergency contact: Name, number and relationship*

Counseling Investment Agreement*

Yes
No

The cost for a one-time consultation with a counselor is $130 per hour. If you decide to proceed with formal regular counseling sessions after the consultation, the suggested investment can be found on the sliding scale at www.theowencenter.com/cost-of-counseling. By selecting yes, you agree to pay the $130 investment at the time of your appointment.

Email

This field is for validation purposes and should be left unchanged.

The Owen Center Personal Profile Form – Consultation

Counseling Agreement

Personal Information