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CLIENT FORMS FOR MINORS

Counseling Fee Sheet
Counseling Fee Sheet

(Please initial and date each statement.)

The current fee for counseling sessions is $70. The payment is due at the time of service at the beginning of the session. Grace For All Families counseling practice accepts the following as payment: cash, credit or debit card, or personal checks.

Checks should be made payable to Grace For All Families. In the event of a returned check, the client should make every effort to pay for the session as soon as possible.

Grace For All Families has a 24-hour cancellation policy. Please be courteous of my time and the time of others- if you cannot keep the appointment, let me know so someone can have it. Failure to cancel or reschedule within 24 hours of your appointment will result in a $20 office charge to be paid at the next visit. No-shows to appointments results in the forfeiture of services provided by Grace For All Families.

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Minor Counseling Information Sheet
Minor Counseling Information Sheet
Family Info

(one per line)

Counseling/Mental Health Background
Goals

(Parents: please fill out this section if child is younger than 13. If they are 13 or older, have them fill out this section themselves.)

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Personal/Family History
Personal/Family History

(Please fill out completely with your information)

Any requests for statements, affidavits, subpoenas needed for family court, etc, are subject to Clergy Privilege and will be reviewed by Dr. Ransom on a case by case basis. According to Georgia Mental Health and Developmental Disabilities Confidentiality Act, subpoenas for any client records need only be answered if sent from a judge’s office, not a lawyer. Thanks Please initial below indicating that you understand this policy.

Regarding requests by clients to appear in court as a professional witness, please be advised that most of the time, the court will not recognize the counselor’s testimony due to hearsay. Please initial below indicating that you understand this policy.

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Grace For All Families Counseling
Please fill out all three forms and submit. You may also download the forms below (Adobe Reader required) and drop off at our office.